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RC202  .C36  The  sequelae  ot  gono 


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FisKE  Fund  Prize  Dissertation.      No.  XLVIII. 


THE  SEQUELAE  OF  GONORRHEA 


IN 


BOTH  SEXES. 


IvIOTTO  : 

"  The  Way  of  Transgressors  is  Hard." 

Proverbs,  xiii,  75. 


BY 

W.   LOUIS   CHAPMAN,    M.    D. 
Providence,  R.  I. 


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CoUege  of  l^ftyiitimi  anb  ^urgeonse 


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RHODE  ISLAND  MEWCALSOCIETY 


FiSKE  Fund  Prize  Dissertation.    No,  XLVIII. 


THE  SEQUELAE  OF  GONORRHEA 


IN 


BOTH  SEXES. 


IVIOTTO: 

"  The  Way  of  Transgressors  is  Hard." 

Proverbs,  xiii,  i$. 


BY 

W.  LOUIS    CHAPMAN,    M.  D.       ' 
Providence,  R.  I. 


PROVIDENCE: 

Snow  &  Farnham,  Printers, 

1905. 


T^HE  Trustees  of  the  Fiske  Fund,  at  the  annual  meeting  of  the 
'^  Rhode  Island  Medical  Society,  held  at  Providence,  June  1,  1905, 
announced  that  they  had  awarded  a  premium  of  two  hundred  and 
fifty  dollars  to  an  essay  on  "The  Sequelae  of  Gonorrhea  in  Both  Sexes," 
bearing  the  motto  : 

"The  Way  of  Transgressors  is  Hard." 

The  author  was  found  to  be  W.  Louis  Chapman,  M.  D.,  of  Provi- 
dence, R,  I. 

CHRISTOPHER  F.  BARKER,  M.  D.,  Newport,  R.  I., 
CHARLES  V.  CHAPIN,  M.  D.,  Providence,  R.  L, 
FRANK  B.  FULLER,  M.  D.,  Pawtucket,  R.  I., 

Trustees. 

HALSEY  De  wolf,  M.  D.,  Providence, 

Secretary  of  the  Trustees. 


SYNOPSIS. 


I.  Introductory, — Etiology  always  complex — Xormal  bacteriology 

of  the  genitalia — The  great  frequency  of  gonorrhea — its  cura- 
bility— The  scope  and  significance  of  this  essay. 

II.  Bactkriological   Considerations.  —  Cultural  characteristics 

— Gonotoxin — Experimental  inoculations — Reinfection — auto- 
reinfection — Immunity — Requirements  for  positive  diagnosis 
— Blood  cultures — The  blood  in  gonorrheal  disease — Gonor- 
rhea in  horses  (original). 

III.  The  Mechanics  of  Gonorrheal  Complications.  —  Paths  of 

extension  of  infection — Xatural  barriers  to  extension — Instru- 
mentation trauma  —  Experimental  study  of  instrumentation 
trauma  (original) — Ureteral  catheterization — Traumatic  agen- 
cies in  operations  on  the  female  genitalia  —  Experimental 
studies  on  silver  nitrate  and  corrosive  sublimate  to  determine 
possible  cause  of  stricture  and  ulceration. 
Latent  Gonorrhea,  anatomy  of — Illustrative  cases. 

IV.  Sequelae  Common  to  Both  Sexes. 

Affections  of  the  Eye. — Avenues  of  infection — Ophthalmia — Ex- 
periments with  toxin,  causing  blindness,  pathology. 
Iritis. 

Iridochoroiditis. 
Panophthalmitis. 

Causing  Ear  Disease. 

Stomatitis. — Gross  and  minute  pathology — Gingyvitis. 

Arthritis. — Pathology — Clinical  features. 

Periostitis. — Cases. 

Myositis. — Pathology. 

Abscess  and  Phlegmon. 

Cystitis. — Of  the  male — Of  the  female — Causes  and  pathology. 

Nephritis.  —  Anatomical  approaches  —  Pyonex>hrosis  and  peri- 
nephritie  abscess. 

3 


4  SYNOPSIS. 

Of  Bectum. — Pathology — Cases. 

Skin  Diseases. — Eczema — Phagadenic  ulcers — Maculae  gonor- 
rhoicae — Pruritus — Erythemata — Dactylitis. 

Diseases  of  the  Nervous  System. — Neuralgia — Neuritis — Muscu- 
lar atrophy — Meningitis. 
Neurasthenia. 

Pleurisy. 

Pneumonia. — Pathology  and  cases. 

Endocarditis  and  Myocarditis. — Pathology — Cases. 

Phlebitis  and  Arteritis. 

General  Systemic  Invasion. — Sources — Pathology — Cases — Re- 
covery possible. 

V.     Sequelae  Peculiak  to  the  Male. 

Prostatic  Involvement. — Anatomical  limitations  of  suppurative 
process — Pathology — Abscess — Predisposing  to  hypertro- 
phy— Phlebitis  of  prostatic  plexus. 

Epididymitis —  Orchitis  —  Vesiciilitis  (original).  —  Pathology  — 
Anatomical  limitations — Sequelae  of  these. 

Balanitis — Cowperitis.,  etc. 

Sterility  in  the  Male. 

Peritonitis  in  the  Male. — Cases. 

VI.     Sequelae  Peculiar  to  the  Female. 

Vaginitis. — Pathology — Xerosis  and  atresia. 

Bartholinitis — Skene'' s  Glands. 

Stricture  Urethrae. 

Endometritis — Perimetritis — Pelvic  Abscess. 

Ovaritis. — Pathology. 

Salpingitis. — Pathology  (original) — Of  infants — Cases. 

Sterility. — Of  female. 

Complicating  Pregnancy  and  the  Puerperium. — Anatomical  and 
mechanical  features — Puerperal  fever — Causing  abortion. 

Peritonitis.  —  Predisposing  factors — Approaches  —  Question  of 
operation  in  gonorrheal  cases  —  Cases  —  Comparison  with 
streptococcus  infections — Differential  diagnosis. 

VII.     Conclusions.  —  Is  gonorrhea  a  predisposing  factor  in  genito- 
urinary tuberculosis  and  neoplasms  ? 
Exhibit  of  Photomicrographs. 


PREFACE. 

It  will  at  once  be  evident  that  this  essay  is  a  work 
of  compilation  and  investigation.  Of  compilation, — 
because  most  of  our  knowledge  is  but  recently  ac- 
quired and  is  to  be  found  only  in  very  recent  research 
monographs  and  case  reports.  Of  investigation, — 
because  the  writer  presents  herewith  the  results  of 
original  work  on  the  mechanical  effects  of  traumatism, 
the  pathology  of  gonorrheal  salpingitis,  prostatitis  and 
seminal  vesiculitis,  and  the  comparative  effects  of 
silver  and  mercury  salts. 

The  writer  wishes  to  acknowledge  his  obligation  to 
Dr.  Tolles,  Assistant  Pathologist  to  the  Rhode  Island 
Hospital,  for  valuable  pathological  material. 


I. 

Tjie  Sequelae  of  Gonokehea  in  Both  Sexes. 

Thkough  the  recent  studies  of  Adami  (Jn.  Am. 
Med.  Assn.  xxxiii,  1500),  Ford  (Trans.  Assn.  Am. 
Phys.  XV,  398),  Nichols  (Jnl.  Med.  Res.  xl,  No.  2),  and 
others,  who  found  that  both  pathogenic  and  saphro- 
phytic  bacteria  were  occasionally  found  in  apparently 
normal  tissues,  an  additional  duty  has  been  imposed 
on  students  of  the  causes  of  pathological  conditions. 
Before  determining  the  cause  of  a  bacterial  disease  it 
is  first  necessary  to  inquire  into  what  may  be  termed 
the  normal  bacteriology  of  the  part.  This  is  of  parti- 
cular importance  in  any  inquiry  into  bacterial  disease 
of  the  genito-urinary  organs  of  either  sex.  Through 
the  researches  of  Kronig,  Bumm,  Doleris,  Martin, 
Schroeder,  Winter  and  His,  we  know  that  the  uterus, 
vagina  and  urethra  contain  a  variety  of  bacteria : 
Asakura  (Zeit.  f.  d.  Krank.  der  Harn.  xvi,  Heft  iii) 
has  found  streptococci  in  the  urethras  of  14  out  of 
112  healthy  men.  Thus,  at  the  outset  of  this  study, 
it  is  evident  that  it  is  not  at  all  easy  to  ascribe  condi- 
tions to  the  gonococcus  alone,  that  many  of  the  com- 
plications of  gonorrhea  are  due  to  a  mixed  infection, 
and  that  some  of  our  most  suggestive  and  important 
cases  are  contributions  to  the  bacteriology  of  other 
species  also. 

That  gonorrheal  urethritis  is  a  very  common  and 
widespread  disease  cannot  be  questioned.  But  it  can- 
not be  justly  claimed  that  the  percentage  of  cases  in 

7 


5  THE    SEQUELAE    OF    GONOKEHEA 

males  is  as  high  as  is  often  asserted,  and  the  writer 
would  take  issue  with  all  statements  of  70%,  80%  and 
90%  of  all  males  in  large  cities  being  or  having  been 
infected.  (Johnson,  Am.  J.  Obst.  Feb.  1904.)  The 
writer  has  been  unable  to  find  proof  of  any  such 
figures.  But  few  statistics  will  bear  criticism,  and 
only  those  from  rehable  sources  will  be  offered  in  this 
essay.  In  the  Heidelberg  obstetrical  clinic  27%  of 
108  pregnant  women  had  gonorrhea.  In  Zweifel's 
private  practise,  but  11%  of  his  patients  had  the 
disease.  In  1930  gynecological  cases  Sanger  found 
but  230  cases  of  gonorrhea  and  of  1617  pregnant 
women  Schwartz  found  clinical  gonorrhea  in  but  77. 
The  committee  appointed  by  the  American  Medical 
Association  to  investigate  the  status  of  gonorrhea  as  a 
cause  of  surgical  diseases  of  women,  have  concluded 
that  of  all  pelvic  disorders  requiring  operation,  40% 
are  due  to  gonorrhea.  Figures  such  as  these,  well 
supported  by  records,  are  sufficient  to  disprove  the 
extravagant  statements  so  often  made  in  current 
literature. 

It  is  no  easy  matter  to  discuss  the  question  of 
the  curability  or  incurability  of  acute  and  chronic 
gonorrheal  urethritis,  upon  which  the  development  of 
complications  so  much  depends.  Many  pages  might 
be  devoted  to  this  subject,  but  for  brevity  it  may  be 
stated  that  the  following  are  the  chief  reasons  for  the 
extreme  chronicity  of  the  primary  disease :  —  non- 
professional treatment:  absence  of  treatment  until 
complications  appear :  alcoholism  and  venery  during 
the  course  of  the  disease :  unscientific  treatment :  the 
cultural  characteristics  of  the  gonococcus :  the  ana- 
tomical by-paths  inaccessible  to  medicaments  :  and  the 


IX    BOTH    SEXES.  9 

various  concomitants  of  venereal  disease.  Many  other 
features  will  be  apparent  in  various  parts  of  this 
work. 

Although  it  is  clearly  beyond  the  scope  of  this 
paper  to  discuss  methods  of  treatment,  it  is  of  the 
greatest  importance  to  note  the  progressive  trend  of 
therapeutics  and  prophylaxis.  Recent  additions  to 
the  medical  and  surgical  armamentaria,  together  with 
the  dissemination  of  popular  knowledge  of  the  hygiene 
of  venereal  cases,  have  not  only  contributed  in  an 
immeasurable  degree  to  the  curability  of  gonorrhea 
but  have  greatly  inhibited  its  spread  and  prevented 
systemic  complications.  For  example,  —  caustic  and 
irritating  injections  are  now  rarely  used,  preference 
being  given  to  recently  devised  silver  salts ;  divulsion 
of  the  urethra  has  largely  given  place  to  internal 
urethrotomy;  patients  are  now  told  of  the  communi- 
cability  of  the  disease  and  urged  to  co-operate  with  the 
physician  in  his  efforts  to  bring  about  a  complete  cure. 
These  are  but  a  few  of  the  ncAver  ideas  in  treatment, 
upon  which  so  much  depends  as  regards  complications. 
In  proof  of  the  efficiency  of  modern  methods  witness 
the  accounts  of  epidemic  ophthalmia  neonatorum  with 
its  wholesale  destruction  of  eyesight  recorded  in  early 
writings ;  and  the  experience  of  Fuchs  who  found  that 
for  every  100  patients  with  gonorrhea  neonatorum, 
15  nurses  acquired  ophthalmia. 

In  opposition  to  the  time-honored  view,  once  in- 
fected always  infected,  attention  should  be  called  to 
the  many  cases,  known  to  every  practitioner,  of 
gonorrhea  which  go  on  to  complete  resolution  in  one 
or  two  months,  which  are  followed  by  no  sequelae 
whatever,  and  later  marriage  of  the  infected  party  is 


10         THE  SEQUELAE  OF  GONORRHEA 

followed  by  healthy  o:ffspring  with  no  involvement  of 
the  maternal  genitalia.  The  great  difficulty  of  com- 
piling statistics  on  this  aspect  of  the  subject  is  at  once 
apparent. 

In  an  investigation  such  as  this  the  sociolo- 
gist will  find  information  regarding  the  variety  of 
complications  possible  in  gonorrhea,  of  value  in  the 
ever-increasing  efforts  designed  to  bring  people  to  a 
keener  realization  of  social  evils.  To  the  popular 
mind  there  is  no  more  cogent  argument  than  plain 
exposition  of  cause  and  effect,  and  a  propaganda  based 
on  a  more  complete  knowledge  of  this  disease,  with 
the  suppression  of  the  many  false  ideas  still  prevalent 
regarding  its  transmission  and  curability,  will  do  much 
towards  diminishing  its  frequency. 

The  economist  will  find  the  influence  of  this  disease 
on  reproductivity  an  important  factor  in  the  study  of 
pauperism,  crime,  indigence  and  race  suicide. 

The  student  of  scientific  medicine  will  find  an  ex- 
position of  the  forces  underlying  the  complications 
and  sequelae  of  gonorrhea  and  cases  of  gonorrheal 
infection  which  duplicate  nearly  all  varieties  of  clinical 
phenomena  caused  by  other  pathogenic  bacteria. 


IN    BOTH    SEXES.  11 


II. 

Bacteriological  Considerations. 

In  order  to  appreciate  the  functions  of  the  gono- 
coccns  and  to  understand  its  effects  on  the  human 
orga,nism,  it  is  important  to  review  the  less  well-known 
features  of  its  biology  and  to  cite  representative  ex- 
amples of  its  pathogeny  derived  from  experimentation. 

The  gonococcus  differs  in  many  particulars  from 
nearly  all  other  pathogenic  bacteria,  —  in  its  cultiva- 
tion, specific  toxin,  selective  affinities  and  the  lesions 
it  causes,  it  is  unique. 

Cultivation. — It  cannot  be  cultivated  with  the  same 
ease  as  B.  typhosus,  B.  diphtheriae,  B.  coli  com., 
streptococci  and  staphylococci,  but  grows  best  on 
solidified  blood  serum,  blood  agar,  and  Wertheim's 
medium.  The  latter  consists  of  one  part  fluid  serum, 
preferably  human  serum  from  the  placenta  or  effusion 
of  pleurisy  or  hydrocele,  and  two  parts  of  liquified 
agar  at  40°  C.  Multiplication  best  occurs  at  the  body 
temperature  and  ceases  at  25°  C.  Colonies  appear 
soon  after  24  hours  in  separate  semi-transparent  discs 
of  undulate  margin  and  irregularly  rounded  shape, 
reaching  their  maximum  on  the  fourth  day  and  usually 
dying  out  before  the  ninth  day.  Successive  trans- 
plantations are  usually  unsuccessful,  but  Heiman  has 
been    able   to   keep   the  gonococcus   alive  in    culture 


12  THE  SEQUELAE  OF  GONORKHEA 

media  for  as  long  a  time  as  82  days  and  has  trans- 
planted as  many  as  25  times.  The  generally  accepted 
view  that  this  organism  does  not  grow  on  other  media 
is  disputed  by  Schonz,  Urbon  and  Wildholz  (Deut. 
med.  Woch.  Mch.  3,  1904),  who  have  successfully  cul- 
tivated it  on  ascitic  fluid,  glycerine  agar,  bouillon, 
gelatine  and  glucose  agar  and  horse  serum.  These 
observers  suggest  the  possibility  of  a  closer  relation 
between  the  genococcus  and  the  diplococcns  intra- 
cellularis  meningitidis  of  Weichselbaum,  on  account  of 
these  cultural  characteristics.  Until  more  evidence  is 
available,  however,  we  must  consider  the  latter  as  a 
distinct  species,  and  in  the  discussion  of  gonorrheal 
affections  of  the  nervous  system,  disorders  caused  by 
it  will  be  omitted. 

According  to  Sternberg  the  gonococcus  is  killed  by 
60°  C  in  10  minutes  and  by  experimentation  Rudis- 
Jicinsky  (N.  Y.  Med.  J.  1901,  Ixxiii,  364)  has  found 
that  it  is  killed  by  the  X-rays  in  35  minutes  if  in  an 
acid  medium  and  in  40  minutes  if  in  alkaline. 

Young  (Jhns.  Hopk.  Hospt.  Rpts.  ix,  684)  reports 
an  interesting  observation  in  which  gonorrheal  fluid 
aspirated  from  a  wrist  joint  showed,  after  a  long 
search,  but  two  leucocytes  each  containing  two  gono- 
cocci.  After  36  hours  incubation  in  ascitic  agar,  great 
numbers  of  leucocytes  filled  with  gonococci,  some  con- 
taining as  many  as  400  could  be  readily  seen.  This 
interesting  and  unusual  observation  illustrates  the 
rapid  multiplication  of  the  gonococcus  and  also  the 
fact  that  the  leucocytes  are  ready  to  take  them  up 
even  in  artificial  media. 

Experiments  made  by  Wertheim  (Arch.  f.  Geb.  u. 
Gyn.   1902,  xlii,   192)  and  verified   by  a   number   of 


IN    BOTH    SEXES.  13 

others  are  of  both  scientific  and  sociological  signifi- 
cance. Obtaining  a  pure  culture  of  gonococci  from  a 
man  with  gleet  of  two  years  duration  he  attempted 
reinfection  of  the  original  urethra  but  always  failed. 
When  inoculated  into  a  normal  urethra,  typical  acute 
gonorrheal  urethritis  was  produced.  Material  from  this 
urethritis  transplanted  into  the  original  urethra  caused 
a  fresh  gonorrhea,  which,  after  running  a  typical  six 
weeks'  course,  subsided  into  the  chronic  gleet  formerly 
existing. 

For  absolutely  positive  diagnosis,  three  conditions 
must  be  satisfied,  —  the  morphology,  staining  reac- 
tions and  cultural  characteristics.  In  doubtful  cases 
of  interest  and  in  those  of  medico-legal  importance  all 
three  of  these  features  must  be  noted.  It  is  not  only 
necessary  to  find  the  characteristic  biscuit-shaped 
cocci,  arranged  in  pairs  and  within  the  margin  of  the 
leucocytes,  staining  with  all  basic  aniline  stains  and 
completely  decolorising  by  Gram's  method,  it  is  also 
to  be  plated  out  by  Wertheim's  method,  and  must 
show  typical  colonies  from  which  the  gonococcus  can 
be  reclaimed.  In  staining  smears  portions  of  a  cul- 
ture of  staphylococcus  aureus  may  be  placed  on  the 
same  slide  for  comparison. 

Gonotoxin  may  be  isolated,  and  experiment  shows 
that  it  alone  may  cause  inflammation  and  destruction 
of  tissue.  It  is  found  that  the  toxin  varies  in  strength 
under  different  conditions,  as  do  cultures,  that  cultures 
sterilized  by  heat  may  be  as  injurious  to  animals  as 
the  liidng  organisms,  and  that  animals  which  are  not 
susceptible  to  the  organism  itself  may  be  affected  by 
the  toxin. 


14  THE    SEQUELAE    OF    GONORRHEA 

DeChristmas  (Ann.  de  I'lnst.  Past,  xiv,  331,  609) 
employed  a  mixture  of  one  part  ascitic  fluid  and  three 
parts  bouillon  for  a  medium.  Twelve  days  growth 
must  take  place  before  the  culture  has  toxic  properties, 
and  then  most  of  the  organisms  are  dead,  the  toxin 
evidently  being  formed  by  the  disintegration  of  their 
bodies.  The  toxin  is  precipitated  with  other  proteids 
hy  absolute  alcohol,  is  soluble  in  glycerine,  is  albu- 
minoid in  character,  is  not  dialyzable,  resists  60°  C.  for 
one  hour,  but  is  changed  by  75°  C.  in  15  minutes. 

Randolph  (Am.  J.  Med.  Sci.  Nov.  1902)  has  verified 
the  studies  of  de  Christmas  and  Schaefer  and  has  ob- 
tained a  toxin  from  the  filtrate  of  a  gonococcus  culture 
in  agar  with  two  parts  of  plain  sugar  and  one  of 
hydrocele  fluid.  An  eight  days  growth  was  covered 
with  chloroform  for  twelve  hours,  it  was  then  scraped 
on  and  mixed  with  sterile  water  or  bouillon.  His 
experiments  with  the  toxin  will  be  referred  to  in  the 
discussion  of  gonorrheal  affections  of  the  eye. 

A  satisfactory  anti-gono toxin  has  not  yet  been 
elaborated. 


Inoculations.  —  The  injection  of  pure  cultures  into 
the  peritoneum  of  white  mice  causes  localized  purulent 
peritonitis  with  penetration  of  the  subendothelial 
connective  tissue,  but  the  organisms  do  not  thrive  and 
the  inflammation  soon  subsides.  Injected  into  the 
joints  of  rabbits,  guinea-pigs  and  dogs  an  acute  in- 
flammation is  produced  which  soon  dies  out, — showing 
conclusively  that  in  these  animals  the  gonococcus  has 
no  enduring  power  and  that  they  have  a  partial  im- 
munity.    Inoculation  of  pure  cultures  and  gonorrhea 


IN  BOTH  SEXES.  15 

pus  into  the  urethras  of  animals  are  negative  and  do 
not  reproduce  the  disease. 

The  subcutaneous  injection  of  2  cc.  of  steriHzed 
culture  into  rabbits  causes  inflammation  and  infiltra- 
tion which  soon  continues  to  necrosis.  The  injection 
of  10  cc.  of  the  same  toxin  causes  local  phlegmonous 
inflammation,  the  animal  becomes  sick,  loses  its  appe- 
tite, and  dies  of  chronic  marasmus.  Injected  into  the 
brains  of  guinea-pigs,  spastic  and  paralytic  phenomena 
and  death  in  16  hours  are  caused. 

The  injection  of  0.1  cc.  into  the  human  subject 
causes  pain  at  the  site  of  injection,  chills  and  evening 
elevation  of  temperature  to  38°  C.  At  night  there  is 
pain  in  the  joints  and  headache.  For  two  days  there 
was  pain  and  swelling  at  the  point  of  injection,  but 
these  gradually  disappeared.  (Wassermann,  Cent.  f. 
Bakt.  1897.)  This  material  has  been  used  clinically 
with  the  view  of  mitigating  symptoms,  but  no  curative 
effects  whatever  were  observed ;  on  the  contrary,  the 
symptoms  were  aggravated.  In  order  to  learn  if  the 
toxin  alone  was  capable  of  causing  a  blenorrhagic  dis- 
charge, Wassermann  introduced  it  into  a  normal  male 
urethra,  and,  after  the  lapse  of  a  few  days,  pronounced 
suppuration  ensued.  Similar  experiments  with  the 
toxins  of  other  pathogenic  bacteria  were  negative, 
which  would  seem  to  show  that  the  urethra  is  quite 
tolerant  of  the  toxins  of  other  bacteria,  but  has  a 
specific  reaction  with  the  gonococcus  or  its  toxin. 

A  partial  immunity  to  the  gonococcus  may  be  ac- 
quired, but  is  never  natural  or  congenital.  Indeed, 
there  is  a  slight  natural  immunity  with  advancing 
years,  infants  being  very  susceptible  to  gonorrheal 
invasions,    most   cases   occurring    before    the    agre    of 


16  THE    SEQUELAE    OF    GONOERHEA 

thirty,  and  a  very  much  smaller  number  later  in  life. 
In  experimentation  on  animals  deChristmas  found  an 
increasing  immunity  with  successive  inoculations,  and 
in  the  human  being  there  is  an  acquired  partial  im- 
munity, varying  with  the  course  of  the  infection  but 
never  complete.  The  difficulty  of  distinguishing  be- 
tween a  new  infection  and  an  acute  exacerbation  of  a 
latent  or  uncured  disease,  makes  clinical  evidence  of 
but  little  importance  in  determining  the  immunity 
acquired  by  successive  gonorrheal  infections.  It  has 
been  observed,  however,  at  the  San  Salvador  Hospital 
(Cent.  f.  Gyn.  1901,  No.  3),  where  a  large  number  of 
cases  of  gonorrhea  in  women  are  treated  annually, 
that  reinfection  of  those  cured  in  the  hospital  rarely 
occurs. 

As  to  the  variability  in  virulence  of  the  gonococcus 
and  the  effect  of  its  association  with  other  organisms, 
we  have  as  yet  but  little  accurate  information.  Clini- 
cal experience  shows  that  in  apparently  normal  and 
similar  persons  the  coccus  causes  widely  different 
phenomena,  varying  from  a  slight  catarrh  with  prompt 
resolution  to  intense  and  progressive  inflammation 
with  many  and  varied  sequelae.  Although  it  is  readily 
proved  that  in  the  cultivation  of  the  gonococcus  in 
artificial  media  the  virulency  decreases  with  successive 
generations,  the  opposite  seems  to  be  true  when  the 
germs  are  incubated  in  human  tissues,  and  that  old 
cases  may  furnish  toxins  and  cocci  of  a  very  high 
grade  of  virulence.  The  pregnant  state  seems  to  offer 
particularly  favorable  conditions  for  the  development 
of  the  gonococcus,  although  we  are  as  yet  unable 
to  state  why  on  account  of  our  imperfect  knowledge 
of  the  biochemical  conditions  of  pregnancy. 


IN    BOTH    SEXES.  17 

Blood  Cultures  should  be  taken  oftener  and  would 
undoubtedly  reveal  a  much  larger  number  of  positive 
findings  than  would  be  supposed.  Krause  points  out 
that  they  should  be  made  immediately  upon  the  ap- 
pearance of  any  rise  in  temperature  during  a  gonor- 
rheal infection,  and  that  20  cc.  to  40  cc.  must  be 
taken.  This  is  to  be  mixed  with  glycerine  serum 
agar,  cooled  to  40°  C.  and  incubated  at  37.6°  C,  or  with 
Latimer's  fluid,  which  consists  of  ascitic  fluid  mixed 
with  equal  parts  of  bouillon,  \%  peptone  and  .5% 
Na  CI.  The  search  for  colonies  must  be  thorough,  as 
they  are  often  smaller  than  the  head  of  a  pin. 

Hematology  of  Gonorrheal  Infections.  —  Aside  from 
the  finding  of  the  gonococcus  in  the  blood,  there  is  but 
little  to  distinguish  gonorrhea  from  other  infections. 
There  is  moderate  leucocytosis,  the  eosinophiles  range 
from  .5%  to  11.5%  ;  but  Bettmann  has  observed  them 
as  high  as  25%  in  a  case  of  gonorrheal  epididymitis. 
The  blood  changes  in  gonorrhepJ  rheumatism  are  the 
same  as  those  of  idiopathic  joint  affections. 

Dutzmann,  who  studied  the  blood  in  165  cases  of 
pelvic  suppuration  (Cent.  f.  (jjn.  1903,  No.  47),  con- 
cludes that  a  leucocytosis  of  11,000  to  13,000  points 
to  a  gonorrheal,  while  upwards  of  30,000  is  indicative 
of  streptococcus  infection. 

Although  not  strictly  within  the  scope  of  this  paper, 
the  writer  offers  brief  observations  on  two  cases  of 
gonorrhea  in  mares,  one  a  case  of  bestiality,  the  other 
caused  by  dilitation  of  the  cervix  by  infected  instru- 
ments. The  former  case  was  verified  by  bacteriologi- 
cal examination  by  Professor  F.  P.  Gorham,  the  emi- 
nent bacteriologist  of  Brown   University,  to  whom  I 


18  THE    SEQUELAE    OF    GONOKRHEA  " 

am  indebted  for  the  privilege  of  reporting  the  case. 
The  profuse  vaginal  and  urethral  discharge  began 
about  three  weeks  after  infection  and  rapidly  pro- 
ceeded into  a  severe  and  intractable  cystitis.  The 
latter  case,  although  not  examined  bacteriologically, 
presented  the  following  significant  train  of  symptoms : 
after  three  days  of  general  depression  and  malaise,  a 
purulent  discharge  appeared  at  the  vulva;  physical 
examination  showed  intense  inflammation  of  the 
vagina  and  urethra ;  the  cervix  uteri  was  a  spongy 
rotten  mass  and  was  dimpled  in  stellate  form,  although 
the  mare  had  never  had  a  colt.  With  these  there  was 
great  pain  on  urination,  the  bladder  was  in  a  high 
state  of  inflammation  and  cast  off  large  amounts  of 
pus.  Nausea  and  vomiting  were  persistent.  The 
acute  stage  lasted  about  10  dp.ys  and  gradually  sub- 
sided, the  bladder  and  urethra  being  well  in  14  days, 
but  the  muco-purulent  vaginal  discharge  continued  for 
three  months. 

The  writer  is  unable  to  find  other  cases  of  gonorrhea 
in  animals  in  literature. 


IN    BOTH    SEXES.  19 


III. 

The  Mechanism  of  Gonokeheax  Complications. 

Undek  this  heading  the  writer  invites  attention  to 
those  factors  which  directly  predispose  to  complica- 
tions, the  channels  by  which  infection  proceeds  from 
the  urethra,  paths  other  than  the  urethral  whereby 
the  gonococcus  may  gain  admission  to  the  system, 
and  the  mechanical  or  traumatic  forces  which  further 
gonorrheal  processes  and  open  up  hitherto  uninvaded 
parts.  While  it  is  true  that  urethritis  is  not  always 
of  gonorrheal  origin, — that  Pezzoli  and  van  der  Pluym 
have  found  the  colon  bacillus,  Legrain  the  B.  Typho- 
sus, and  others  that  a  variety  of  bacteria  may  qfe,use 
purulent  urethritis, — the  fact  remains  that  nearly  all 
cases  of  urethritis  are  gonorrheal  and  show  the  coccus 
at  some  time  in  the  course  of  the  disease. 

Gonorrhea  extends  first  by  continuity  of  tissue  in  a 
manner  quite  analogous  to  bacterial  diseases  of  the 
respiratory  tract.  Wherever  there  is  continuity  of 
epithelium  the  progress  of  inflammatory  disease  de- 
pends upon  the  nature  and  virulence  of  the  infection, 
the  specific  susceptibility  of  the  cellular  elements,  and 
the  mechanical  barriers  which  offer  physical  resist- 
ance. In  the  male  genito-urinary  organs,  unbroken 
tracts  may  be  traced  from  the  urethra  into  the  bladder, 
thence  through  the  ureters  to  the  kidneys;  through 
the  ducts  into  the  seminal  vesicles,  vas  and  epididymis. 


20         THE  SEQUELAE  OF  GONORRHEA 

In  the  female  the  urinary  tracts  upwards  from  the 
m^ethra  are  substantially  the  same  as  the  male,  and 
the  epithelium  of  the  vagina  continues  with  slight 
structural  gradations  into  the  uterus,  tubes  and  peri- 
toneum. What  then  are  the  chief  forces  which  favor 
the  spread  of  gonorrheal  infection,  what  are  the  natural 
defences  of  the  organism  against  its  inroads,  and  what 
is  the  natural  course  of  the  disease  uninfluenced  by 
treatment? 

Certain  mechanical  barriers  are  evident.  Of  very 
great  importance  in  the  preventing  of  ascending  in- 
fection of  the  urinary  tract  is  the  downward  flow  of 
urine  whereby  infectious  particles  are  washed  out. 
The  urethra,  ureters,  and  seminal  ducts  are  potential 
and  not  actual  tubes,  their  walls  being  in  apposition 
unless  distended  by  outflowing  fluids,  a  state  which 
renders  agglutination  by  mucous  or  inflammation  easy 
and  thus  materially  prevents  the  upward  progress  of 
bacteria.  As  to  the  form  of  the  Fallopian  tubes  in 
this  respect,  the  writer  has  made  a  large  number  of 
transverse  sections  to  determine  whether  the  tubes 
were  normally  collapsed  or  were  actually  tubular  with 
a  free  and  patent  lumen.  It  appears  that  the  latter  is 
the  case  and  that  they  have  sufficient  rigidity  to  pre- 
vent collapse  and  the  apposition  of  mucous  surfaces. 
This  is  a  point  of  great  importance  as  it  is  distinctly 
favorable  to  gonorrheal  salpingitis.  Sections  of  the 
seminal  vesicles  show  that  they  also  are  patent  and 
rigid  tubes.  The  mucous  plug  which  obstructs  the 
cervix  in  the  gravid  uterus  is  a  barrier  of  the  greatest 
importance  to  the  upward  extension  of  gonorrhea 
acquired  during  pregnancy. 

Any  cellular  form  may  be  invaded  by  the   gono- 


IN   BOTH    SEXES.  21 

COCCUS,  but  it  finds  its  most  favorable  soil  in  columnar 
epithelium  and  its  next  best  habitat  in  the  transitional 
form.  In  the  female  the  epithelium  of  the  vagina  is 
thick  and  stratified;  that  of  the  uterus  ciliated  colum- 
nar; that  of  the  cervix  both  cylindrical  and  columnar; 
the  oviducts  are  lined  with  ciliated  columnar  epithe- 
lium ;  the  urethra  is  paved  with  stratified  transitional 
epithelium  except  at  the  internal  orifice  where  it  is 
stratified  pavement.  In  the  male  the  urethra,  Cowper's 
glands,  ejaculatory  ducts,  prostatic  ducts,  and  epididy- 
mis have  columnar  epithelium  and  the  vasa  deferentia 
and  seminal  vesicles  have  stratified  columnar.  It  is 
thus  seen  that  the  gonococcus  does  not  everywhere 
find  its  favorite  environment.  There  is  no  evidence 
that  pavement  forms  exert  any  particular  inhibitory 
action  on  the  gonococcus  or  that  it  has  any  cytolytic 
aflinity,  but  it  seems  probable  that  the  squamous  form 
of  the  cells,  by  their  small  amount  of  protoplasm  and 
their  dense  compact  manner  of  assemblage  are  me- 
chanical rather  than  biological  defences  of  the  organ- 
ism, and  that  they  not  only  prevent  extension  along 
tubular  tracts  but  also  penetration  into  the  tissues. 


■    Effects  of  Instrumentation. 

Instrumentation  of  the  male  urethra  is  performed 
largely  for  the  relief  of  gonorrheal  complications. 
The  suppurating  surface  of  the  urethra  in  gonorrhea 
is  to  be  considered  as  protective  against  the  deep 
involvement  of  the  mucosa.  Were  this  not  so,  glandu- 
lar and  periurethral  comphcations  would  be  frequent 
or  universal  instead,  of  occasional.  It  is  evident  that 
anything  which   abrades   the    urethral   epithelium  or 


22  THE  SEQUELAE  OF  GONORKHEA 

denudes  it  of  its  protective  hyperplasia,  deprives  it  of 
its  natural  mechanical  means  of  defence,  affords  a 
means  of  deeper  seated  bacterial  infection  and  may 
drive  bacteria  into  the  tissues  if  force  be  used.  Instru- 
ments do  harm  in  two  waj^s,  —  by  the  tissue  damage 
the}'^  inflict  and  by  the  infection  they  may  carry.  If 
the  urethra  be  over  distended  by  the  use  of  instruments 
of  too  great  calibre,  ruptures  and  minute  hemorrhages 
result.  If  the  point  of  the  sound  be  forced,  perfora- 
tions or  rupture  of  soft  jDarts  may  occur.  With  some 
it  has  been  the  practice  to  dilate  the  urethra  in  acute 
and  chronic  urethritis,  to  iron  out  its  wrinkles  and 
folds  that  all  parts  might  be  bathed  by  injected  medi- 
caments. It  has  been  found  by  many  observers,  how- 
ever, that  this  was  often  productive  of  harm  and  that 
prostatic  and  periurethral  complications  were  more 
frequent  than  when  there  was  no  instrumentation. 
The  writer  shares  in  the  view  that  instrumentation  of 
the  suppurating  urethra  should  be  conducted  with  the 
greatest  care,  and  that  it  is  a  dangerous  procedure 
unless  the  tract  is  fairly  free  from  pathogenic  bacteria, 
— a  thing  which  is  absolutely  im^DOssible  in  the  early 
stages  of  gonorrheal  urethritis.  In  the  instrumenta- 
tion of  any  part  invaded  by  the  gonococcus  it  may  be 
claimed  that  safety  increases  with  lapse  of  time  after 
inoculation,  but  that  latency  may  exist  after  very  long 
periods  of  time.  Clinical  realizations  of  the  teaching 
that  complications  are  often  caused  by  instrumentation 
and  traumatism  are  so  frequent  that  it  is  not  necessary 
to  assemble  cases.  Whenever  it  is  necessary  to  oper- 
ate on  the  urethra  it  should  be  repeatedly  cleansed 
with  irrigating  solutions  by  means  of  a  soft  retrojec- 
tion  catheter. 


IN    BOTH    SEXES.  23 

It  has  been  argued  that  the  use  of  injections  of  any 
kind  renders  involvement  of  the  pars  prostatica  more 
probable.  In  the  writer's  opinion  the  great  majority 
of  cases  of  anterior  urethritis  become  prostatic  without 
any  interference,  and  urethral  injections  without  intra- 
urethral  instrumentation  do  no  harm  unless  the  solution 
be  irritating. 

The  traumatism  of  horseback  or  bicycle  riding, 
blows  on  the  perineum  or  excessive  muscular  exertion 
very  frequently  cause  exacerbation  of  an  acute  or 
chronic  gonorrheal  urethritis,  with  immediate  exten- 
sion into  the  epididymis,  prostate  or  inguinal  glands. 
This  is  probably  explained  by  the  forcing  of  bacteria 
from  the  superficial  layers  of  the  lu-ethra  into  the  sub- 
mucous tissue,  thereby  starting  a  new  inflammation 
and  increasing  the  activity  of  the  old.  A  similar 
condition  may  be  noted  in  the  female ;  infection  may 
be  resident  in  the  vagina  and  urethra  and  the  intro- 
duction of  an  infected  sound  be  responsible  for  gonor- 
rheal endometritis  which  promptly  follows.  Were 
instrumentation  of  the  female  urethra  practised  as 
often  as  that  of  the  male,  bladder  involvement  would 
be  more  frequent  in  women. 

Experimental  Study  of  Instrumentation  TraumatisTn. 

Failing  to  find  accurate  information  in  text-books, 
the  writer  has  made  observations  on  the  amount  of 
force  necessary  to  cause  tissue  damage  to  the  urethra, 
prostate,  bladder  and  periurethral  tissue.  The  ordi- 
nary instruments  used  in  treatment  and  diagnosis  were 
used,  —  sounds  of  correct  curve,  calibres  from  2  to 
32  F.,  Gouley's  staff,  wire  stylets  ^nd  filiform  bougies. 


24         THE  SEQUELAE  OF  GONORRHEA 

The  amount  of  force  can  be  very  accurately  measured 
by  scales  attached  to  the  instruments. 

But  little  force  is  necessary  to  introduce  a  well-oiled 
sound  into  the  normal  urethra;  often  they  will  enter 
of  their  own  weight  and  rarely  is  more  than  four  ounces 
required.  At  the  prostatic  curve  of  the  urethra,  with 
proper  guidance,  four  ounces  is  quite  enough  for  an 
instrument  of  20  F.  calibre.  With  larger  sounds  one 
ounce  more  force  may  be  required.  But  little  force  is 
required  to  puncture  the  membranous  urethra.  With 
small  bougie  or  stylet  four  or  six  ounces  may  be 
enough,  and  with  larger  instruments  a  force  of  two 
pounds  or  more  is  almost  sure  to  do  damage.  On  the 
dissected  prostate  it  is  found  that  any  force  above  four 
pounds  is  certain  to  penetrate  the  prostatic  tissue.  If 
the  instrument  be  a  stylet  with  either  sharp,  round  or 
blunt  point,  penetration  occurs  with  pressure  of  one 
pound  or  over.  When  one  recollects  that  occasionally 
the  stylet  of  silk  catheters  project  from  the  eye,  and 
that  considerable  force  is  often  used,  it  is  not  surpris- 
ing that  false  passages  are  occasionally  made,  that 
ducts  are  entered,  and  that  suppurative  processes  are 
implanted. 

When  the  urethra  or  prostate  are  once  perforated; 
but  very  little  force  is  required  to  continue  on  into 
the  soft  cellular  tissue  of  the  ischio-rectal  fossa,  the 
space  of  Retzius,  or  even  the  pelvic  peritoneum. 

The  mucous  membrane  of  the  bladder  is  exceed- 
ingly delicate.  Any  force  above  one  pound  may  be 
sufficient  to  cause  rupture  or  separation  from  the 
muscular  coat,  to  which  it  is  bound  by  areolar  tissue 
of  exceedingly  loose  texture.  Considerable  force  is 
required  to  puncture  the  bladder  so  resistant  are  its 


IN    BOTH    SEXES.  25 

tunics,  which  may  resist  a  force  of  six  pounds  with  a 
sound  of  only  8  F.  Sharp-]~»ointed  instruments,  how- 
ever, easily  penetrate  when  force  of  upwards  of  half  a 
pound  is  exerted. 

These  figures  represent  averages  of  findings  upon  a 
number  of  individuals  and  upon  normal  organs.  With 
pre-existing  disease  the  force  required  to  do  damage 
would  be  much  less.  Inflamed  and  infiltrated  urethras 
are  very  easily  abraded  and  very  gentle  instrumenta- 
tion is  often  followed  by  hemorrhage.  Papillomata  of 
the  bladder  are  so  delicate  that  even  the  passage  of  a 
soft  catheter  may  be  followed  by  bleeding  and  a  sound 
or  sharp-pointed  instrument  may  cause  hemorrhage 
which  is  controlled  only  by  powerful  astringents. 
From  these  experiments  on  the  cadaver,  in  view  of 
the  very  considerable  force  which  we  know  is  occa- 
sionally used  in  the  instrumentation  of  the  urethra,  it 
seems  remarkable  that  "urethral  fever"  and  sj'stemic 
infection  are  not  of  even  greater  frequency. 

The  recent  introduction  of  ureteral  catheterization 
as  a  means  of  diagnosis  and  treatment  necessarily 
carries  with  it  the  greater  opportunities  for  injury  to 
the  bladder,  ureter  and  kidneys,  as  well  as  of  trans- 
planting infectious  materials.  The  catheter  might 
cause  abrasions  in  the  epithelium  and  imperfections  in 
its  surface  might  easily  carry  particles  for  deposition 
further  up.  Now,  the  very  conditions  for  which  ure- 
teral catheterization  are  done  are  those  which  would 
afford  abundant  material  for  sepsis,  and  we  find  an- 
other application  of  the  teaching  already  urged, — that 
of  frequent  washings  of  the  bladder  and  urethra  before 
catheterization  of  the  ureters  is  done.  The  passage  of 
urethral  calculi  may  cause  abrasions  in  which  infectious 


26  THE    SEQUELAE    OF    GONORRHEA 

particles  may  lodge,  as  is  illustrated  by  a  case  of 
gonorrheal  pyelitis  of  the  writer's  to  be  reported. 
Contusions  of  bladder  and  kidney  regions  and  of  the 
testicles  favor  gonorrheal  involvement  by  lowering 
tissue  resistance  and  by  hemorrhagic  areas  in  which 
the  gonococcus  might  become  lodged. 

Traumatic  Agencies  in  the  Female.  —  Among  the 
important  traumatic  factors  to  which  the  female  is 
subjected  are  those  which  would  compress  a  gonorrheal 
Fallopian  tube  and  cause  it  to  exude  pus  through  its 
fimbriated  end  or  to  rupture.  This  trauma  is  usually 
due  to  one  of  the  following  classified  circumstances : — 

i.  Incident  to  Parturition  at  any  Time  in  Preg- 
nancy. —  Lacerations  of  the  uterus,  cervix,  vagina 
and  perineum,  afford  abundant  opportunities  for  the 
ingress  of  bacteria,  and  are  a  very  common  cause  of 
puerperal  fever.  With  the  increase  in  size  of  the 
gravid  uterus  the  broad  ligaments  become  tense,  the 
abdominal  wall  is  tightly  stretched  over  the  fundus 
and  considerable  pressure  is  exerted  on  the  tubes, 
which  is  greater  still  if  they  be  distended  with  pus. 
With  the  violent  contractions  of  the  uterus  at  term 
the  compression  must  be  very  great,  and  it  is  not  at 
all  surprising  that  gonorrheal  peritonitis  occasionally 
follows  promptly  after  labor. 

ii.  Operations  on  the  Female  Genitalia.  —  Besides 
those  already  mentioned  we  have  instrumental  deliv- 
ery, curetting  of  the  uterus,  dilatation  of  the  cervix 
with  instruments  or  tents,  abdominal  and  pelvic  opera- 
tions of  any  kind  upon  tissues  invaded  by  the  gono- 
coccus, and  the  transfer  of  gonorrheal  material  from 


IN    BOTH    SEXES.  27 

the  vagina  to  the  rectum  through  faulty  technique. 
Niebergall  (Beit,  zur  Geb.  u.  Gyn.  ii,  Heft  1)  reports 
two  cases  in  which  dilatation  of  the  cervix  for  the 
relief  of  sterility  was  followed  by  pelvic  gonorrhea. 
The  first,  a  woman  of  thirty-three,  dilated  with  in- 
struments which  was  followed  in  three  days  by  a 
profuse  discharge  containing  gonococci,  with  chills, 
high  temperature,  severe  abdominal  pains  and  the 
prompt  development  of  pyosalpinx.  The  other,  a 
woman  of  twenty-one,  dilated  with  tents  which  caused 
the  same  sequence  of  symptoms. 

iii.  Accidental  abdominal  injuries  which  act  in  the 
same  way  as  those  already  described. 

In  no  disease,  unless  perhaps  tuberculosis  be  ex- 
cepted, is  auto-reinfection  so  frequent  as  in  gonorrhea. 
In  the  male,  the  anterior  urethra  infects  the  urethra 
and  the  bladder ;  with  improvement  in  the  former  the 
latter  offers  opportunity  for  new  generations  of  gono- 
cocci and  the  process  is  perpetuated ;  the  word  is  apt. 
In  the  female  an  infected  tube  distributes  gonococci  to 
the  uterine  cavity,  the  peritoneum,  vagina  and  ure- 
thra, and  upon  one  of  these  becoming  free  from  in- 
flammation and  bacteria,  the  means  of  reinfection  is 
at  hand. 

Brief  Report    of  iExi^erhnental    Study    of  Mercuric 
Chloride  and  Silver  Nitrate. 

The  writer  has  observed  a  number  of  cases  in  which 
the  use  of  injections  of  corrosive  sublimate  has  been 
followed  by  stricture  of  the  urethra,  exacerbation  of 
the  urethritis,  prostatitis  and  epididymitis.     And,  al- 


28  THE    SEQUELAE    OF    GONORRHEA 

though  the  discussion  of  stricture  of  the  urethra  is 
intentionallj'  omitted  from  this  paper  for  reasons  al- 
ready given,  it  seems  quite  germain  to  discuss  one  of 
its  causes.  In  the  first  series  of  experiments  solutions 
of  corrosive  sublimate  were  injected  into  the  tissues  of 
dogs,  rabbits,  guinea-pigs  and  frogs,  and  in  all  cases  it 
was  found  that  in  any  strength  over  j^-qq  it  im- 
mediatel}'  sets  up  a  violent  inflammatory  reaction, 
tlu'ombosis  of  all  small  vessels,  perivasculitis,  capillary 
rupture,  and,  if  the  injection  is  not  followed  by  the 
death  of  the  animal,  a  hard  phlegmon  develops  at  the 
site  of  the  injection.  That  it  causes  increase  in  con- 
nective tissue  appears  from  the  photomicrograph  taken 
of  a  section  of  the  tongue  of  a  frog  into  which  a  a-oVo" 
solution  had  been  injected.  This  is  proven  such  by 
comparison  with  normal  organs  and  by  Mallory's  con- 
nective tissue  stain. 

When  introduced  into  the  stomach  of  a  frog  a 
2  oVo"  solution  causes  death  in  about  two  weeks,  the 
only  symptoms  observed  being  salivation,  an  occasional 
convulsion  and  progressive  asthenia.  The  stomach  is 
of  a  dark  gray  color  and  the  intestines  show  the  ap- 
pearance of  a  violent  enteritis.  Sections  show  infil- 
tration of  the  mucosa,  in  some  places  desquamation  of 
the  epithelium,  and  throughout  the  mucous  membrane, 
and  occasionally  in  the  submucous  tissue,  there  is  evi- 
dent a  distinct  increase  in  the  normal  connective  tissue 
of  the  part.  This  finding  also  was  verified  by  check 
observations  and  comparison  with  normal  specimens. 

Silver  Nitrate.  —  A  y^^-  solution  injected  into  the 
stomach  of  the  frog  causes  but  shght  disturbance  in 
the  animal,  —  it  seems  uneasy,  peristalsis  is  increased 


IN    BOTH    SEXES.  29 

and  large  quantities  of  mucous  are  expelled  from 
the  cloaca.  The  stomach  is  pale,  anemic,  and  almost 
pure  white  in  color,  and  contains  a  normal  amount 
of  secretion.  There  are  no  signs  of  irritation  in  the 
intestines.  A  solution  ten  times  as  strong  causes  in- 
tense discomfort  and  irritability  on  the  part  of  the 
animal.  There  is  great  buccal  irritation,  profuse  muc- 
ous discharge  from  the  mouth  and  the  expulsion  of 
much  mucous  and  epithelium  from  the  cloaca.  The 
stomach  shows  intense  congestion;  in  some  places 
there  is  complete  desquamation  of  mucosa,  but  the 
inflammatory  reaction  is  not  as  great  as  was  surmised 
from  the  symptoms  and  behavior  of  the  animal.  The 
frog  is  not  killed,  but  is  sluggish  in  its  movements 
and  shows  cutaneous  argyria. 

Frog  killed,  tissues  killed  in  Zenker's,  sectioned  in 
celloidin,  stained  with  Delafield's  hematoxylene  and 
Mallory's  connective  tissue-stain.  But  little  change  is 
observed  in  the  stomach  of  frog  into  which  the  y^-g- 
solution  has  been  applied.  The  epithelium  is  for  the 
most  part  unbroken  and  there  is  but  little  exudate. 
The  gastric  mucosa  to  which  the  10%  solution  has 
been  applied  shows  denudation  of  mucosa  in  places 
with  the  beginning  of  ulceration  as  illustrated  in  the 
photomicrograph.  There  is  no  increase  of  connective 
tissue. 

Objections  might  be  raised  to  the  use  of  the  stomach 
of  the  live  frog  for  these  experiments  with  silver 
nitrate,  on  account  of  the  precipitation  which  occurs 
with  chlorine  in  any  form.  The  same  thing,  however, 
always  occurs  in  the  urethra,  which  is  always  in  a 
state  of  salinity  on  account  of  the  chlorides  of  the 
urine  as  well  as  of  the  urethral  secretion.     Indeed,  it 


30  THE    SEQUELAE    OF    GOISTORRHEA 

is    this  property  which   prevents  this   chemical  from 
causing  lesions  in  clinical  work. 

In  order  to  verify  the  teaching  that  the  gonococcas 
particularly  predisposes  to  the  proliferation  of  con- 
nective tissue,  the  writer  has  examined  a  large  number 
of  sections  from  the  prostate,  urethra,  tubes  and  ovaries 
in  gonorrheal  disease.  He  is  unable  to  find  in  these 
any  evidence  that  they  contain  more  connective  tissue 
than  is  usually  found  in  conditions  of  acute  and  chronic 
inflammation  caused  by  other  organisms.  It  is  a  nat- 
ural process  for  the  walls  of  any  suppurating  sinus  to 
contract,  examples  of  which  are  found  in  the  contrac- 
tion and  dimpling  of  healed  abdominal  sinuses,  fecal 
fistulas,  ischiorectal  abscesses  and  the  like.  So,  also, 
is  it  to  be  expected  that  the  urethra,  transformed  in 
gonorrhea  into  a  suppurating  sinus,  would  occasionally 
contract  from  the  tissue  changes  which  necessarily 
result  in  the  healing  of  a  deeply  ulcerated  surface. 
Did  space  permit  the  writer  could  offer  a  number  of 
photomicrographs  of  gonorrheal  tissues,  which,  by 
comparison  with  the  normal  of  the  organ  affected, 
would  readily  show  the  validity  of  this  argument. 

Latent  Gonorrhea  as  a  Cause  of  Comjjlicatioiis. 

This  is  one  of  the  most  important  features  in  the 
production  of  gonorrheal  sequelae.  By  latency  a  non- 
progressive focus  of  gonococci  is  meant  and  not.  a 
sub-acute  gonorrhea  as  is  very  frequently  supposed. 
Anatomically  this  state  is  one  of  encystment,  a  group 
of  (;occi  are  surrounded  by  a  capsule  of  connective 
tissue  which  is  non-vascular,  and  no  opportunities  for 
nourishment  and  growth  are  afforded.     With  the  dis- 


i:?i    BOTH    SEXES.  31 

turbance  of  such  a  nidus  and  the  rupture  of  the  cap- 
sule, together  with  focal  hemorrhage  such  as  very 
frequently  accompanies  even  slight  traumatism,  the 
bacteria  become  active  and  at  once  begin  their  destruc- 
tive work. 

Instances  in  great  number  might  be  offered,  but  the 
following  are  of  particular  interest: — A  man  acquires 
gonorrheal  urethritis  in  his  younger  days  but  supposes 
himself  cured.  Seeking  professional  advice  for  pros- 
tatic disease  at  the  age  of  sixty,  sounds  are  passed  for 
diagnostic  purposes.  A  latent  focus  is  disturbed  and  a 
septic  process  is  inaugurated  which  rapidly  invades  the 
blood  causing  fatal  gonorrheal  valvular  endocarditis. 

A  case  attended  by  the  writer :  —  A  man  claims  to 
have  been  cured  of  gonorrhea  eleven  years  prior  to 
wife's  confinement,  at  which  time  the  child  becomes 
affected  with  gonorrheal  ophthalmia  and  the  mother 
with  gonorrheal  endometritis  and  peritonitis.  In  cases 
such  as  this  there  is  the  probability  of  error,  on  ac- 
count of  the  lack  of  truthfulness  on  the  part  of  the 
patient;  but  their  philosophy  is  not  at  all  obscure. 
The  muscular  activity  of  parturition  opens  a  nidus  of 
bacteria,  local  infection  occurs  which  is  speedily 
distributed. 

Another  case  of  the  writer's :  —  A  man  supposes 
himself  cured  of  urethritis,  but  is  injured  by  falling, 
which  causes  return  of  his  dysuria,  with  the  addition 
of  hematuria  and  true  gonorrheal  cystitis,  which 
becomes  chronic  and  intractable.  An  attack  of  ure- 
thral calculus  furnishes  opportunity  for  ascending 
infection  with  the  development  of  pyelitis  with  its 
characteristic  signs  which  subsides  after  a  time  leaving 
the  pre-existing  conditions. 


62  THE  SEQUELAE  OF  GONORRHEA 

The  state  of  latency  is  uot  limited  entirely  to  the 
gonococcus,  but  our  most  frequent  and  important 
clinical  illustrations  are  furnished  by  it.  Baumgarten 
and  Beliring  have  shown  that  tubercle  bacilli  may 
remain  inactive  for  a  long  time.  Malaria  furnishes 
another  example  of  latency,  and  recently  Panichi 
(Cent.  f.  Bakt.  1905,  xxxvi,  25)  has  shown  that 
bacteria,  particularly  pneumococci,  may  survive  in  a 
highly  unfavorable  environment  without  causing  patho- 
logical states  until  some  special  condition  favorable  to 
their  metabohsm  occurs. 

Many  cases  of  sub-acute  gonorrhea  present  no  gross 
appearances  whatever.  In  the  male  a  sub-acute  state 
manifests  itself  occasionally,  and  as  any  urethral  dis- 
charge is  an  evidence  of  disease  the  patient,  if  properly 
instructed  previousl}^,  is  likely  to  resume  treatment. 
In  the  female,  however,  the  infection  may  be  uterine 
or  vaginal  and  the  discharge  very  slight ;  and  as  vaginal 
discharge  is  very  common  in  women,  and  there  may 
be  no  symptoms  save  those  which  are  frequently  due 
to  other  causes,  the  condition  is  not  recognized.  And 
then,  again,  we  occasionally  find  cases  in  which  a 
supposedly  cured  gonorrhea  suddenly  extends  without 
any  apparent  cause,  —  mthout  history  of  accident, 
traumatism  or  bodily  exertion.  In  women,  years  after 
the  inception  of  the  gonococcus,  without  any  warning 
or  apparent  cause  for  acute  exacerbation,  a  pyosalpinx 
or  perimetritis  develops  which  runs  an  acute  course 
and  merges  into  chronicit3^ 

The  symbiosis  of  the  gonococcus,  then,  may  at  any 
time  become  a  state  of  ^;arac^^^sm  and  cause  the 
complications  with  zohich  this  ^9aper   deals. 


IN    BOTH    SEXES.  33 

The  question  naturally  arises  as  to  the  probability 
of  complications  in  untreated  cases  of  gonorrheal  ure- 
thritis, a  question  which  at  present  cannot  be  answered. 
In  an  experimental  case  See  {op.  cit.)  found  that  com- 
plications arose  in  spite  of  every  care,  and  Le  Fort 
found  from  his  records  that  epididymitis  was  more 
frequent  in  the  untreated.  We  know,  too,  that  a  very 
considerable  percentage  of  cases  in  women  first  seek 
professional  advice  for  the  sequels  of  the  disease,  and 
we  must  conclude  that  although  certain  complications 
are  furthered  by  the  mechanical  features  just  discussed, 
they  cannot  be  held  wholly  responsible. 


34         THE  SEQUELAE  OF  GONORRHEA 


IV. 

Sequelae  Common  to  Both  Sexes. 


Ocidar  ComjMcations  of  Gonorrhea. 

Gonorrhea  affects  the  eye  both  by  the  living  cocci 
and  their  toxin  apart  from  the  parent  organism,  and 
infection  is  by  direct  external  implantation  and  by  the 
blood  and  lymphatic  streams.  The  former  causes 
conjunctivitis  and  ophthalmia;  and  the  latter  scleritis, 
iritis,  retinitis  and  suppurative  keratitis. 

Ophthalmia  is  one  of  the  most  common  complications 
of  genital  gonorrhea,  and  is,  of  course,  most  frequent 
among  infants.  In  1,498  cases  of  ophthalmia  collected 
by  Stephenson  (Am.  J,  Obst.  xliii,  554),  60.17%  were 
gonorrheal.  In  1,178  blind  patients,  Dumas  found 
that  1,070  became  so  from  curable  diseases,  and  of 
these  69%  were  from  ophthalmia  neonatorum.  Out 
of  58,000  blind  persons.  Hirst  found  that  15,000  were 
made  so  by  gonorrheal  ophthalmia.  Neisser  claims 
that  there  are  now  30,000  persons  in  Germany  in 
whom  blindness  was  caused  by  this  disease ;  and,  at 
institutions  for  the  blind,  gonorrhea  is  considered  a 
cause  of  46%  of  all  cases  in  Paris,  20%  in  Switzerland, 
and  in  25%  to  50%  in  American  institutions.  Modern 
methods  of  treatment  must  again  be  invoked;  for  in 
200  cases  of  gonorrheal  ophthalmia  treated  by  Hirsch- 
berg  but  six  terminated  in  complete   blindness.     In 


IN    BOTH    SEXES.  35 

378  cases  treated  by  Hein,  317  were  completely  cured 
and  61  had  impaired  vision;  in  161  cases  Eperon  had 
but  elev^  bad  results,  and  of  these  seven  presented 
lesions  when  first  treated.  King  considers  that  25% 
of  all  blindness  is  due  to  gonorrhea.  Crede  found 
10.8%  of  the  bailies  in  the  Leipzig  Lying-in  Hospital 
affected  with  it;  but,  within  a  few  years,  under  his 
improved  method  of  prophylaxis  and  treatment,  this 
was  reduced  to  less  than  .1%.  'It  has  been  supposed 
that  the  infant  acquires  the  infection  during  its 
passage  through  the  parturient  canal,  which  is  true 
in  some  cases,  but  in  a  great  many  the  infection  is 
received  after  birth ;  for  our  knowledge  of  the  biology 
of  the  gonococcus  teaches  that  its  period  of  incubation 
is  from  a  few  hours  to  six  to  ten  days.  In  476  cases 
studied  by  Andrews  (N.  Y.  Med.  J.  1855,)  57  began 
before  the  fifth  day  after  birth,  134  before  the  ninth 
day,  94  before  the  fifteenth  day,  and  194  after  this 
time.  The  writer  has  seen  a  number  of  cases  develop 
after  the  tenth  day.  This  knowledge  shows  how 
necessary  it  is  to  practice  the  strictest  precautions  in 
suspected  cases.  The  late  development  of  ophthalmia 
is  explained  by  the  well-known  exacerbation  of  latent 
or  sub-acute  infection  by  the  mechanical  forces  of 
parturition  already  described. 

In  proof  of  the  supposition  that  ophthalmia  might 
be  caused  by  the  toxin  as  well  as  by  the  living  organ- 
ism, deChristmas  (Ann.  de  ITnst.  Past,  xiv,  331)  pre- 
pared a  sterile  toxin  which  he  found  distributed  both 
in  the  culture  medium  and  in  the  body  of  the  bac- 
terium. He  found  that  it  was  albuminoid  in  character, 
soluble  in  glycerine,  precipitated  by  absolute  alcohol 
and  destroyed  by  high  temperatures.     Ten  drops  of 


36  THE  SEQUELAE  OF  GONORRHEA 

his  filtrate  when  injected  into  the  eye  caused  intense 
congestion  of  the  upper  half  of  the  eyeball,  most  in- 
tense at  the  point  of  injection  and  fading  with  radial 
distance.  With  decreasing  doses  the  effect  diminished, 
and  with  three  drops  only  a  slight  redness  at  the  point 
of  injection,  covering  one-fourth  of  the  eye-globe,  was 
observed.  If  the  injection  be  made  into  the  anterior 
chamber  instead  of  into  the  conjunctiva,  corneal  cloudi- 
ness, hypopyon,  and  even  loss  of  the  entire  eye  from 
panophthalmitis  may  result. 

For  Eandolph's  method  of  preparing  gono toxin,  see 
Bacteriological  Considerations.  In  his  experiments  on 
the  eye  the  conjunctival  sacs  of  white  and  gray  rabbits 
were  kejDt  full  of  filtrate  for  periods  of  from  fifteen 
minutes  to  eight  hours,  but  in  no  case  save  one  was 
there  any  reaction  whatever.  In  this  case  a  five-hour 
instillation  caused  ocular  and  palpebral  congestion 
followed  by  conjunctivitis  with  slight  muco-purulent 
discharge.  The  repetition  of  the  experiment  into  the 
other  eye  of  the  same  animal  was  entirely  negative. 
When  injected  into  the  conjunctiva  ten  drops  of  his 
filtrate  caused  intense  reaction.  Sections  bhow  a  thick 
exudate  resting  on  the  epithelium,  distended  blood 
vessels,  and  the  sub-epithehal  connective  tissue  filled 
with  closely  packed  leucocytes.  When  injected  into 
the  anterior  chamber  five  drops  caused  pericorneal 
congestion,  iritis  with  cloudiness  of  the  aqueous,  —  all 
disappearing  within  seven  days. 

Gonorrheal  ophthalmia  usually  appears  within 
twenty-four  hours  of  inoculation  with  redness  and 
swelling  of  the  lids,  burning  and  smarting  pains, 
systemic  malaise  and  slight  elevation  of  temperature. 
Great  swelling  of  the  eyelids,  chemosis  of  the  conjunc- 


IN    BOTH    SEXES.  37 

tiva,  hemorrhages  from  the  rupture  of  small  vessels 
and  an  infiltration  ring  around  the  cornea  may  result 
in  extreme  cases.  If  neglected,  perforation  with  hernia 
of  the  iris  may  take  place,  thus  admitting  infection  to 
the  interior  of  the  eye  and  causing  panophthalmitis ; 
or  the  process  may  be  arrested  at  this  stage  and  result 
in  staphyloma  of  the  cornea. 

Histologically  the  entire  conjunctiva  is  infiltrated 
with  leucocytes,  the  inflammation  being  most  intense 
in  the  superficial  layers.  There  is  more  or  less  com- 
plete desquamation  of  the  epithelium  and  its  replace- 
ment by  a  dense  layer  of  pus  corpuscles  containing 
gonococci.  In  most  cases  the  cocci  are  limited  to  the 
outermost  layers  of  the  sub-epithelial  connective  tissue 
in  rows  or  masses  between  the  fibre  bimdles ;  occasion- 
ally they  may  penetrate  deeply  into  the  conjunctival 
tissue.  The  teaching  that  the  formation  of  a  croupous 
membrane  is  a  natural  protective  measure  assisting 
the  healing  process  does  not  apply  in  this  case,  and 
experience  teaches  that  cure  is  accomplished  only  by 
the  prompt  use  of  bactericides,  —  indeed,  it  is  often 
necessary  to  employ  in  the  conjunctival  sac  solutions 
which  would  not  be  tolerated  in  the  urethra. 

Rarely  a  case  is  seen  in  which  a  child  is  born  with 
gonorrheal  ophthalmia,  —  in  such  cases  there  is  usually 
a  history  of  delayed  labor  with  early  rupture  of  the 
membranes,  thus  allowing  vaginal  infection  to  invade 
the  amnionic  sac  before  birth. 

Gonorrheal  ophthalmia,  both  in  adults  and  infants, 
is  often  a  primary  affection  and  may  be  the  source 
from  which  complications  proceed.  It  is  a  frequent 
cause  of  gonorrheal  arthritis  of  the  young  and  even  of 
the  newly  born. 


38  THE    SEQUELAE    OF    GONORRHEA 

In  order  to  prove  if  it  were  possible  for  conjunc- 
tivitis to  be  caused  by  normal  lochia,  Zweifel  inocu- 
lated the  conjunctiva  but  with  negative  results. 

Iritis  and  Iridoehoroiditis. 

These  may  or  may  not  be  associated  with  gonorrheal 
conjunctivitis  and  they  develop  much  more  rapidly 
than  ordinary  rheumatic  iritis.  The  inflammation  is 
serous  rather  than  plastic  and  presents  in  brief  the 
following  features :  sudden  onset,  very  rapid  develop- 
ment, severe  ocular  pain,  rapid  and  complete  loss  of 
vision  due  to  serous  infiltration  of  the  iris  and  choroid 
with  cloudiness  of  the  aqueous  and  vitreous  precluding 
the  possibility  of  ophthalmoscopic  view  of  the  fundus. 
Fibrinous  exudate  is  never  observed  and  synechiae 
are  rare,  but  when  they  do  occur  are  feeble.  Five 
cases  reported  by  Bull  (Med.  Rec.  Dec.  20, 1902,)  were 
all  secondary  to  gonorrheal  arthritis  and  one  was  fol- 
lowed by  gonorrheal  endocarditis. 

Pathology  :  in  gonorrheal  iritis  there  is  small  celled 
infiltration  of  the  iris  which  is  general  or  may  be  in 
scattered  foci  or  along  the  vessel  sheaths.  There  may 
be  small  hemorrhages  giving  the  appearance  of  punc- 
tate ecchymoses  or  the  inflammation  may  go  on  to 
suppuration  with  the  appearance  of  a  fibrinous  exu- 
date and  pus  in  the  anterior  chamber. 

Gonorrheal  Panoi^hthahnitis  is  caused  in  two  ways, 
—  by  the  perforation  of  corneal  ulcers  from  the  de- 
structive lesions  of  conjunctivitis  allowing  the  evacua- 
tion of  the  eye  fluids  thereby  causing  collapse  of  the 
globe,  —  or  by  the  rapid  invasion  of  eye  tissues  by  the 


IN    BOTH    SEXES.  39 

gonococcus  which  causes  at  first  intense  congestion 
and  swelling,  but  afterwards  contraction  and  shrivel- 
ling with  progressive  destructive  suppuration. 

Dacrj^ocystitis  of  gonorrheal  origin  does  not  differ 
materially  from  that  caused  by  other  pyogenic  organ- 
isms. 

Otitis  Media  and  Mastoiditis. 

Very  rarely,  indeed,  gonorrheal  infection  shows 
itself  in  the  ear  as  is  illustrated  in  the  unusual  case 
observed  by  Trow  (Med.  Rec.  May  2,  1903,  693)  oc- 
curring in  a  man  of  fifty-two  years.  Although  the 
patient  denied  venereal  disease,  purulent  otitis  media 
was  followed  by  mastoiditis,  the  pus  from  which 
showed  typical  gonococci.  Operation  was  followed 
by  prompt  and  uneventful  recovery. 

Stomatitis  and  Gingyvitis. 

Gonorrheal  stomatitis  is  very  rarely  observed  in 
adults,  but  is  quite  frequently  seen  in  the  new  born,  the 
source  of  infection  being  usually  the  maternal  genital 
tract.  The  disease  starts  with  small  punctate  cream- 
colored  patches  on  the  buccal  mucous  membrane  which 
soon  enlarge  and  coalesce  and  form  membranous  areas 
which  are  even  in  outline  and  slightly  raised  above 
the  surface.  The  condition  resembles  oral  thrush  or 
diphtheria,  there  is  inflammation  with  infiltration  of 
the  tissues  of  the  tongue,  the  palatal  and  buccal 
mucous  membranes  soon  become  covered  with  a 
croupous  deposit  which  consists  of  exfoliated  epi- 
thelium and.  pus  cells.  Smears  from  these  show  the 
gonococcus  if  taken  early  in  the  course  of  the  disorder, 


40         THE  SEQUELAE  OF  GONORRHEA 

but  later  may  be  negative  on  account  of  the  tendency 
of  the  coccus  to  be  overgrown  by  other  bacteria,  of 
which  there  is  a  great  variety  in  the  mouth.  In  all 
cases  this  process  is  distinctly  local  and  does  not  spread 
unless  the  system  be  greatly  reduced. 

A  case  reported  by  Vines  (Br.  Med.  J.  Feb.  21, 
1903,  425,)  shows  not  only  that  gonorrhea  may  be- 
come engrafted  in  the  mouth  as  may  syphilis,  but  also 
that  it  may  cause  pyorrhea  alveolaris  and  gingyvitis 
of  the  most  severe  form.  A  man  who  had  been  suffer- 
ing with  gonorrheal  urethritis  for  a  month  used  an 
infected  toothpick ;  the  gums  shortly  became  inflamed, 
red,  swollen,  painful,  bleeding  and  spongy,  all  the  teeth 
became  loose,  every  socket  was  bathed  in  pus,  and  the 
condition  resisted  all  forms  of  treatment  until  silver 
preparations  were  used.  A  temperature  of  101°  F. 
showed  a  low  grade  of  toxemia  from  absorption. 

Gonorrheal  Arthritis. 

This  disease  is  quite  distinct  from  ordinary  rheu- 
matism and  is  caused  by  the  local  deposition  of  gono- 
cocci  in  or  al30ut  an  articulation.  It  may  occur  at 
any  age,  even  in  the  new  born,  and  occurs  most 
frequently  during  gonorrheal  urethritis.  Fournier, 
Besnier  and  Grisolle  observed  the  ratio  to  be  one  case 
in  64,  50  and  35  cases  of  urethritis  which  are  probably 
minimum  estimates.  Men  are  more  frequently  a:ffected 
than  women,  possibly  because  their  more  active  physi- 
cal life  offers  more  opportunities  for  traumatism  to  the 
articulations.  In  52  cases  observed  by  Schuller,  34 
were  in  males  and  18  in  females. 

The   symptoms  are   quite   distinctive.      The   onset, 


IN    BOTH    SEXES.  41 

though  often  sudden  is  not  accompanied  by  the  febrile 
reaction  so  characteristic  of  acute  articular  rheumatism 
and  often  the  disease  is  quite  febrile  throughout  its 
course,  the  elevation  being  two  degrees  or  less.  Hy- 
perpyrexia indicates  mixed  infection  or  the  involve- 
ment of  other  organs.  Occasionally  the  pain  may  be 
severe,  but  usually  there  is  but  little  pain  and  no 
intense  suffering  with  motion  and  manipulation  so 
characteristic  of  acute  articular  rheumatism.  Swelling 
is  an  early  symptom  due  to  effusion  of  fluid  into  the 
joint  cavity,  bursae  or  tendon  sheaths,  or  the  j^ei"!- 
articular  tissues.  Suppuration  is  rare  and  usually  due 
to  a  mixed  infection,  but  if  such  cases  are  incised  early 
the  gonococcus  may  be  found  in  the  tissues  or  effu- 
sion. In  all  these  cases  there  is  a  marked  tendency 
to  fibrous  anchylosis  and  they  are  extremely  chronic, 
lasting  for  months  or  even  years. 

Joints  affected.  —  The  knee  is  involved  more  fre- 
quently than  any  other  joint.  In  a  series  of  119  cases 
compiled  by  Garrod,  the  knee  was  infected  in  83  cases, 
the  ankle  in  32,  fingers  and  toes  in  23,  the  hip  in  16, 
the  wrist  in  14,  the  shoulder  in  12,  the  elbow  in  11, 
the  temporo-maxillary  in  6,  the  tarsus  and  metatarsus 
in  5,  the  sacro-iliac  in  4,  the  sterno-clavicular  in  3,  the 
chrondro-costal  in  2  and  the  tibio-fibular  in  1. 

In  62  cases  studied  by  Markheim  (Deut.  Arch.  f. 
klin.  Med.  Ixxii,  186,)  one  joint  was  involved  in  13 
cases,  two  in  12,  three  in  11,  four  in  7.  Endocarditis 
was  observed  four  times,  iritis  three  times,  sciatica  once. 
Complete  anchylosis  of  joints  was  observed  in  five 
cases,  limitation  of  motion  in  7  and  the  gonococcus 
was  demonstrated  in  the  blood  in  but  two. 


42  THE    SEQUELAE    OF    GONORRHEA 

On  account  of  the  persistency  of  the  gonococcus  and 
its  tendency  to  become  latent,  relapses  upon  over  ex- 
ercise or  injury  are  very  common. 

Gonorrheal  Periostitis  closely  resembles  gonorrheal 
arthritis  and  may  be  acute  and  remain  as  a  simple  in- 
flammation of  the  periosteum,  or  it  may  extend  into 
the  bone  and  become  a  true  osteitis.  (Phillipet,  Gaz. 
hebd.  de  Med.  et  Chir.  1901,  No.  79.)  The  condition 
begins  with  pain  over  a  distinctly  circumscribed  area 
of  bone  with  mounding  and  puffiness  of  the  overlying 
tissues.  The  skin  may  be  red  and  shiny.  It  is  usually 
of  very  rapid  development,  comes  on  three  weeks  after 
the  initial  discharge  and  lasts  for  two  or  more  weeks. 
The  symptoms  then  either  disappear  gradually  and 
cause  no  more  trouble  or  else  persist  with  the  develop- 
ment of  plastic  hypertrophic  periostitis  and  more  or 
less  deformity  which  may  endure  for  years.  This,  too, 
is  prone  to  relapse  and  recur  with  fresh  gonorrheal 
infection.  A  frequent  location  of  gonorrheal  periosti- 
tis is  at  the  insertion  of  the  tendo  Achilles,  where  the 
pain  may  be  so  great  as  to  render  the  patient  an  in- 
vahd,  the  slightest  weight  borne  on  the  foot  causing 
intense  pain. 

Fournier  and  Amaral  have  observed  a  progres- 
sive pseudo-nodulated  deforming  polyarthritis  after 
gonorrhea  which  is  characterized  by  periarticular 
Bwellings  of  ihe  extremities  of  the  phalanges,  meta- 
carpal bones  or  great  toe.  Smooth,  hard  exostoses 
form  on  the  extensor  and  lateral  sides,  but  never  on 
the  flexor.  There  is  pain  on  the  first  appearance  of 
the  tumefactions  but  none  later,  nor  is  there  any  red- 
ness of  the  overljdng  tissues.      If  the  inflammation 


IN  BOTH  SEXES.  43 

extends  over  the  joint  between  the  first  and  second 
phalanges,  we  have  the  fusiform  or  radish-shaped  joint 
which  is  pathognomonic  of  the  disease,  but  which 
must  be  differentiated  from  tuberculosis  and  sarcoma. 
Haygarth's  dactylitis  resembles  this  very  closely,  but 
invariably  affects  all  the  fingers  of  both  hands. 

Chronic  osteo-periostitis  of  the  long  bones  also  may 
occur  as  a  complication  or  sequel  of  gonorrhea.  The 
most  common  example  of  this  is  the  hypertrophy  of 
the  diaphysis  of  the  femur  which  occasionally  follows 
gonorrheal  rheumatism  with  the  formation  of  an  indo- 
lent swelling  accompanied  by  an  extreme  degree  of 
atrophy  of  the  muscles  of  the  thigh.  This  affection  is 
extremely  chronic  often  persisting  for  months  or  even 
years  in  spite  of  the  most  sincere  treatment.  It  is 
differentiated  from  syphilitic  affections  by  the  extreme 
painfulness  and  the  amenability  to  specific  treatment 
of  the  latter. 

It  seems  probable  that  gonorrheal  infection  reaches 
these  various  joints  by  the  blood  stream  and  that  their 
lodgment  is  favored  by  the  looped  and  terminal  capil- 
laries which  lie  in  non-yielding  fibrous  tissue  which  is 
constantly  in  motion  and  frequently  exposed  to  trau- 
matism. Cases  are  on  record  in  which  tendon  sheaths 
near  joints  were  involved,  but  the  most  careful  exam- 
ination failed  to  show  any  connection  between  the  two. 
Wounds,  gonorrheal  ophthalmia  and  other  extra-genital 
foci  may  be  the  cause  of  arthritis  and  occasionally,  as 
observed  by  Kimball  (Med.  Rec.  Nov.  14,  1903,  761,) 
the  source  of  infection  is  unknown.  Among  600  ad- 
missions to  the  Babies'  Hospital  of  New  York,  10  cases 
of  gonorrheal  arthritis  occurred ;  eight  of  these  were 
under  three  months  old,  and  of  these  all  but  one  were 


44  THE  SEQUELAE  OF  GONORKHEA 

males.  In  but  one  was  there  conjimcti^dtis  and  that 
developed  after  the  joint  symptoms.  In  none  of  these 
cases  "was  there  urethritis,  vaginitis  or  any  other 
finding  which  would  indicate  the  point  of  entry  of  the 
organism. 

The  course  of  ordinary  cases  of  gonorrheal  arthritis 
is  well  known,  but  the  following  cases  present  points 
of  unusual  interest. 

Gonorrheal  arthritis  and  perichondritis  may  go  on 
to  the  destruction  of  tissue  and  deprive  bones  of  their 
necessary  support,  as  illustrated  by  a  case  of  Widal 
(Soc.  med.  des  Hop.  de  Paris,  26  Jul.  1895,)  in  which 
a  gonorrheal  hydrarthrosis  caused  spontaneous  luxa- 
tion of  the  head  of  the  radius. 

Herman  (Med.  Eec.  May  21,  1904,  815,)  reports,  a 
case  of  multiple  periarthritis  in  a  child  in  which  the 
infection  was  received  through  a  wound  of  the  foot. 

Bordone-Uifreduzze  (Deut.  med.  Woch.  xx,  484,) 
obtained  the  organism  in  pure  culture  from  an  infected 
ankle  joint,  and  established  the  certainty  of  its  etiol- 
ogy by  the  successful  inoculation  of  the  urethra  of  a 
healthy  man. 

Two  cases  of  gonorrheal  affection  of  the  sternal  end 
of  the  clavicle  are  of  interest.  (Jn.  Am.  Med.  Ass. 
Aug.  27,  1904,  608.)  One  in  a  man  of  twenty  which 
occurred  three  weeks  after  the  beo-innincr  of  an  un- 
treated  urethritis;  the  other  a  man  of  twenty-one, 
two  weeks  after  appearance  of  the  urethral  discharge, 
there  appeared  a  globular  swelling  the  size  of  a 
hen's  egg  which  was  at  first  supposed  to  be  a  rapidly 
growing  osteo-sarcoma. 

Illustrative  of  gonorrheal  arthritis  of  the  new  born 
Haushalter  (Arch.  chn.  de  Bordeaux,  iv,  495,)  observed 


IN    BOTH    SEXES.  45 

a  case  in  a  child  of  twenty-eight  days.  Three  days 
after  birth  double  conjunctivitis  appeared  in  very 
virulent  form  causing  loss  of  both  eyes.  Griffon 
(Presse  Med.  10  Fev.  1896,  88,)  reports  a  similar  case 
of  double  purulent  ophthalmia  with  perforation  of  one 
eye  and  suppuration  of  the  right  hip  and  wrist  joints. 
Death  on  the  thirteenth  day  of  the  arthritis  from 
general  pyemia.  Autopsy  showed  gonococci  in  abscess 
cavities  of  both  affected  joints.  Blood  cultures  taken 
a  week  before  death  showed  staphylococcus  albus  and 
a  bacillus  closely  resembling  Klebs  Loeffler.  This 
interesting  case  illustrates  the  co-existence  of  other 
bacteria  which  were  introduced  with  and  by  the 
gonorrheal  infection.  Still  another  case  by  Paulsen. 
(Jhns.  Hop.  Hospt.  Bull,  cxliv,  98.)  A  child  develops 
gonorrheal  ophthalmia  on  the  third  day  which  runs  an 
uneventful  course  and  yields  promptly  to  treatment. 
On  the  eleventh  day  the  left  knee  becomes  swollen 
and  aspiration  of  the  effusion  shows  the  gonococcus  in 
pure  culture. 

Teno- Synovitis  has  been  thoroughly  discussed  by 
Bloodgood  and  Flexner  (Jhns.  Hopk.  Hospt.  Bull.  Ixi, 
68,)  and  by  Jacobe  and  Goldmann  (Beit.  z.  klin.  Chir. 
xii,  672). 

A  monograph  by  Vernon-Jones  (H.  K.  Lewis  Co., 
London)  offers  additional  information  on  gonorrheal 
affections  of  the  joints. 

Myositis. 

Not  only  is  myalgia  a  frequent  accompaniment  of 
gonorrheal  arthritis,  but  the  coccus  actually  invades 
muscular  tissue  and  causes  all  grades  of  inflammation 


46  THE    SEQUELAE    OF    GONORRHEA 

from  infiltration  to  actual  suppurative  destruction.  The 
general  features  of  this  complication  are  best  illustrated 
by  abstracts  of  case  liistories. 

In  a  case  worked  out  by  Ware  (Am.  J.  Med.  Sci. 
cxxii,  11,)  a  man  in  the  fourth  week  of  gonorrheal 
urethritis  is  taken  with  chills,  temperature  and  pains 
in  the  knee  joint.  Several  weeks  later  there  is  pain 
and  swelling  in  the  left  shoulder  joint.  Incision  in 
the  posterior  axillary  fold  shows  turbid  serum,  the 
cultures  of  which  remained  sterile,  but  no  pus.  A 
portion  of  the  muscle,  however,  was  excised  and 
sections  showed  interstitial  inflammation  with  liberal 
scattering  of  gonococci  in  pairs  about  the  nuclei  of 
the  leucocytes  and  in  the  interstices  of  the  muscle. 
Portions  of  the  muscle  fibres  showed  cloudy  swelling 
and  there  was  multiplication  of  the  muscle  nuclei  with 
shrinking  of  the  perimysium.  Between  the  fibres 
there  was  marked  proliferation  of  connective  tissue. 
In  this  case  we  have  another  interesting  example 
of  deep  invasion  by  the  gonococcus  and  of  the 
state  of  fibrosis  which  this  organism  is  supposed  to 
occasion. 

Rona  (Arch.  f.  Derm.  u.  Syph.  1898,  250,)  reports 
two  cases  in  which  inflammation  did  not  go  on  to 
suppuration.  The  first  in  a  man  of  twenty-seven  in 
whom  pain  in  the  thigh  was  followed  by  induration 
which  was  very  tender  on  palpation,  lasted  many 
weeks  and  was  at  no  time  accompanied  by  redness  or 
swelling  of  the  overlying  skin.  The  other  case,  a 
man  of  twenty-seven  with  fourth  attack  of  gonorrhea. 
In  the  second  week  of  the  attack  pain  begins  in  the 
middle  of  the  left  thigh  and  is  followed  by  infiltration 
of  the  fascia  lata  the  size  of  a  saucer.     Rest  in  bed 


IN    BOTH    SEXES.  47 

was  necessary  for  two  weeks,  but  at  no  time  was  there 
any  elevation  of  temperature. 

Eichorst  (Deut.  med.  Woch.  1899,  685,)  records  a 
case  of  a  man  of  fifty-six.  who,  in  the  fourth  week 
of  his  first  attack  of  urethritis,  is  taken  with  severe 
pain  in  the  outer  aspect  of  the  thigh  followed  by  the 
development  of  a  painful  induration  4  by  8  cm. 
Temperature  from  35°  to  38°  C.  Two  weeks  later 
gonorrheal  arthritis  appeared  in  the  wrists. 

Treves  has  observed  a  case  of  gonorrheal  myositis 
in  which  the  muscle  afterwards  became  sclerotic,  the 
condition  resembling  that  which  causes  anchylosis  of 
the  joints. 

Harris  and  Haskell  (Med.  News.  Feb.  21,  1903,  381,) 
have  observed  a  case  in  which  tumefactions  appeared 
in  the  calf  of  the  leg  and  in  the  sacro-lumbar  region. 
Leucocytosis  of  16,000.  Incision  releases  760  cc.  of 
bloody  pus  from  the  abscess  in  the  leg  and  drains  a 
large  intra-muscular  abscess  in  the  sacral  region.  The 
gonococcus  is  demonstrated  in  smears  and  cultures 
from  both. 


Causing  Abscesses  and  Phlegmonous  Inflammations. 

These  may  be  caused  at  almost  any  portion  of  the 
external  surface  of  the  body,  and  are  due  to  direct 
inoculations  or  to  metastasis.  Ophthalmia  and  ure- 
thritis are  the  most  common  antecedent  lesions. 
Gonorrheal  abscesses  are  usually  superficial  but  may 
be  deep  seated,  as  is  shown  in  the  discussion  of  gland- 
ular diseases  and  myositis.  The  pus  from  them  may 
or  may  not  show  the  gonococcus  for  the  reasons  al- 
ready discussed.      The  experiments  of  Wassermann, 


48  THE  SEQUELAE  OF  GONORKHEA 

who  injected  gono toxin  into  his  own  arm  have  already 
been  referred  to. 

Bujivid  (Cent.  f.  Bakt.  u.  Parasit.  1895,  435,)  reports 
an  interesting  case  of  a  man  of  thirty-two  years  with 
posterior  urethritis.  Two  days  after  catheterization 
he  had  severe  chills  for  six  days  which  were  followed 
by  the  development  of  multiple  abscesses  in  the  left 
elbow  joint,  the  right  popliteal  fossa,  the  inner  side  of 
the  left  calf  and  over  the  right  external  malleolus. 

The  writer  has  operated  on  several  periurethral 
abscesses  in  which  smears  showed  the  gonococcus, 
which  did  not  communicate  with  the  urethra  and  which 
healed  quickly  when  incised  from  without.  Such  cases 
prove  conclusively  that  the  coccus  does  penetrate 
below  the  mucosa,  for  in  none  of  these  cases  had  there 
been  any  instrumentation  or  other  traumatism  which 
might  assist  their  progress. 

Gonorrhea  is  a  common  cause  of  abscesses  of  the 
perineum  and  ischio-rectal  fossa,  due  in  some  instances 
to  false  passages  from  instrumentation  and  in  others 
to  gonorrheal  phlebitis  of  the  prostatic  plexus.  Gonor- 
rheal proctitis  may  be  the  cause.  Periurethral 
abscesses  are  so  common  as  to  need  no  special 
discussion. 

The  interior  of  gonorrheal  abscesses  often  presents 
an  appearance  regarded  by  many  as  pathognomonic 
of  the  gonococcus.  This  is  a  characteristic  picture 
with  dark  red  granulations  which  bleed  easily  and 
tend  towards  a  fungoid  appearance.  Abscesses  of 
gonorrheal  origin  in  the  deeper  portions  of  the  peri- 
neum and  ischio-rectal  fossa  differ  from  cutaneous 
suppurations  in  being  very  much  slower  in  healing, 
the  surrounding  surfaces  are  infiltrated  and  spongy 


IN"    BOTH    SEXES.  49 

hut   as   a   rule  not   of    edematous  hardness,  and   the 
systemic  depression  and  anemia  is  often  intense. 

When  pudendal  abscesses  compUcate  syphiHs  they 
may  often  be  termed  syphiUtic  buboes  of  gonorrheal 
origin.  The  system,  already  depressed  by  the  syphi- 
litic virus  allows  invasion  by  other  bacteria,  and  an 
intercurrent  gonorrheal  urethritis  is  very  frequently 
followed  by  enlargement  and  suppuration  of  the  in- 
guinal glands  showing  either  the  gonococcus  or  a 
mixed  infection.  If  of  slow  development  they  may 
be  sterile,  and  if  operation  be  aseptic,  primary  union 
may  be  realized  and  should  be  attempted.  Abscess 
formation  will  be  frequently  referred  to  throughout 
this  work. 

Adetiitis. 

It  was  formerly  thought  that  the  gonococcus  was 
incapable  of  causing  adenitis,  but  recent  examinations 
have  shown  that  while  this  organism  does  not  show 
the  affinity  for  glandular  tissue  exhibited  by  other 
bacteria,  yet  it  is,  of  itself,  quite  capable  of  causing 
adenitis  of  all  grades  and  of  nearly  all  parts.  The 
group  of  glands  just  above  Poupart's  ligament  and 
outside  the  fascia  lata  are  those  most  commonly 
affected,  and  their  enlargement  may  be  looked  for 
after  the  first  week  of  the  urethritis. 

Cervical  adenitis  has  been  caused  by  the  gonococcus 
as  has  been  shown  by  Pettit  and  Pichevin  (Mai.  Cut. 
et  Syph.  1896,  419,)  the  infection  being  either  from 
the  urethra  by  the  blood  stream,  or  else  more  directly 
from  a  wound. 

The  only  special  study  of  the  lymphatics  in  acute 
gonorrheal  urethritis  made   thus  far  is  that  of  Nobl 


50  THE  SEQUELAE  OF  GONOKRHEA 

(Klin,  thera.  Woch.  xxix.),  who  found  the  cocci  in 
the  substance  of  the  glands  in  five  out  of  nine  cases 
studied. 

Mastitis.  —  The  writer  offers  the  report  of  a  case 
of  puerperal  mastitis  occurring  in  a  woman  who  ac- 
quired gonorrhea  shortly  before  pregnancy,  in  which 
multiple  abscesses  requiring  operation  formed  in  the 
left  breast.  There  were  also  small  pustules  in  the 
integument  and  near  the  umbilicus,  also  showing  gono- 
cocci.  Freeth  (Lancet,  Jn.  6,  1904,)  reports  a  case  of 
mastitis  in  the  male,  secondary  to  gonorrheal  urethri- 
tis, the  pus  showing  the  cocci. 

We  see,  then,  that  the  gonoccccue  is  occasionally 
the  cause  of  cutaneous,  cellular  and  glandular  ab- 
scesses, and  that  it  vies  with  the  streptococcus  and 
staphylococci  in  this  respect.  The  philosophy  of  this 
difference  is  apparent  from  the  cultural  characteristics 
of  the  gonococcus. 

Cystitis. 

Cystitis  is  a  very  common  complication  of  either 
acute  or  chronic  gonorrheal  urethritis.  It  occurs  more 
frequently  in  men  than  in  women,  on  account  of  the 
frequent  involvement  of  the  prostatic  portion  of  the 
urethra,  the  tendency  to  stricture,  and  the  preponder- 
ance of  the  various  mechanical  forces  which  we  have 
already  discussed  as  furthering  the  extension  of  bac- 
terial inflammations.  The  various  factors  which  cause 
vesical  congestion,  inseparable  from  gonorrheal  ure- 
thritis, need  not  be  discussed;  but  this  congestion  is 
occasionally  so  great  that  rupture  of  venous  capillaries 
may   take   place,  thus   affording   opportunity  for  the 


IN    BOTH    SEXES.  51 

lodgement  of  the  gonococcus  and  the  development  of 
a  focal  suppuration.  Calculi  or  tumors  of  the  bladder 
act  as  mechanical  irritants  and  cause  a  chronic  cystitis 
which  may  become  gonorrheal  whenever  there  is  the 
added  infection;  papilloma,  in  particular,  acts  as  a 
host  for  bacterial  colonies,  and  the  cystitis  which  such 
a  combination  fosters  is  intractable  and  long  enduring. 

The  pathology  and  symptoms  of  gonorrheal  cystitis 
are  not  distinct  from  that  caused  by  other  organisms. 
The  mucosa  is  swollen  and  congested,  bearing  red 
spots  of  ecchymosis  which  may  break  down  and.  form 
bleeding  ulcerations  with  granulating  surfaces.  The 
ureteral  openings  may  be  obstructed.  In  a  case  of 
Wertheim  (Deut.  med.  Woch.  xvii,  1895,  118,)  of  a 
girl  of  nine  ^'^ears  with  gonorrheal  vulvo-vaginitis, 
arthritis  and  acute  cystitis,  the  excision  of  a  small 
millet  seed  tubercle  on  the  posterior  portion  of  the 
mucous  membrane  of  the  bladder  showed  a  large 
number  of  capillar}^  veins  in  the  submucosa  to  be  filled 
with  large  numbers  of  gonococci,  while  the  arterial 
capillaries  contained  none.  Cultures  from  the  urine 
and  the  tissue  showed  the  gonococcus  in  pure  culture. 

In  an  interesting  case  of  cystitis,  prostatitis,  purulent 
arthritis,  splenic  infarction  and  prostatic  folliculitis, 
observed  by  Finger,  sections  of  the  bladder  showed 
similar  engorgement  of  the  capillaries  with  leucocytes, 
infiltration  of  the  perivascular  tissues  by  the  gonococci, 
and  undermining  of  the  epithelium. 

In  addition  to  these  cases,  the  researches  of  Young 
{op.  cit.)  place  our  loiowledge  of  gonorrheal  cystitis 
upon  a  basis  of  scientific  certainty.  Owing  to  the 
impossibility  of  obtaining  urine  that  was  uncontam- 
inated  by  the  secretions  of  the  urethra  he  aspirated 


52  THE    SEQUELAE    OP    GONORRHEA 

the  bladder  through  the  abdominal  wall  without  harm 

resulting.  One  of  his  cases  is  of  particular  significance. 
Patient  with  chronic  cystitis  of  five  years  duration 
following  gonorrhea,  double  pyonephrosis,  atony  of 
bladder,  retention  of  urine.  Upon  aspiration  of  the 
bladder,  gonococci  were  found  in  pure  culture  and  in 
great  numbers.  At  first  gonococci  alone  were  found, 
then  bacilli  and  streptococci  began  to  appear  in 
increasing  numbers.  On  the  seventeenth  day  there 
were  fewer  gonococci  than  other  bacteria,  and  in  ten 
weeks  they  were  greatly  outnumbered  by  bacilli  and 
streptococci,  both  of  which  were  intracellular  ap.d  in 
great  numbers.  This  secondary  infection  occurred  in 
spite  of  intra-vesical  irrrigations  of  bichlorid  and  the 
most  rigid  aseptic  technique. 


Ascending  Gonorrheal  Infection. 

Having  seen  how  the  bladder  may  become  infected 
from  the  urethra  and  suggested  the  commonness  of 
the  complication,  the  important  question  of  ascending 
infection  naturally  presents  itself.  It  has  already 
been  noted  that  catheterization  of  the  ureters  might 
carry  particles  to  the  renal  pelvis,  and  the  writer  has 
briefly  reported  a  case  in  which  the  injury  inflicted  by 
a  ureteral  calculus  afforded  opportunity  for  secondary 
gonorrheal  infection.  The  question  of  reflux  from  the 
bladder  into  the  ureters  has  received  much  deserved 
attention.  One  recollects  the  intense  pain  in  the 
lumbar  and  kidney  regions  which  accompanies  bladder 
retention  and  disappears  promptly  when  the  distension 
is  relieved.     Lewin  &  Goldsmith  (Virch.  Arch,  cxxxiv, 


IN  BOTH  SEXES.  53 

S.  33,)  showed  that  reflux  took  place  in  anesthetized 
rabbits.  JacobelH  (La  Rif.  Med.  1901,  xvii,  27,)  has 
shown  that  fluids  suddenly  injected  into  the  bladder 
may  pass  up  into  the  ureters,  and  one  might  suppose 
that  the  same  thini>'  would  occur  in  case  of  blows  over 
the  bladder.  Young  and  Stoeckel  were  unable  to  verify 
these  findings,  but  Marcus  (Wien.  klin.  Wocli.  1903, 
xvi,  725,)  observed  both  reflux  and  reversed  ureteral 
peristalsis  in  animals.  Sampson  (Jhns.  Hopk.  Hospt. 
Bull.  Dec.  1904,  341,)  has  made  a  notable  series  of 
experiments  on  dogs,  making  nineteen  transplantations 
of  the  ureter,  and  observed  no  reflux  in  any  degree  of 
bladder  distention  nor  reversed  peristalsis.  There  is, 
however,  considerable  clinical  evidence  that  reflux 
does  take  place  in  the  human  species.  Pozzi  (Cent.  f. 
Gyn.  xvii,  98,)  accidentally  severed  a  ureter  while 
removing  a  large  intraligamentary  ovarian  cyst,  and 
observed  that  urine  came  from  both  ends  of  the  ureter. 
Warschauer  (Berl.  klin.  Woch.  xxxviii,  399),  in  a  case 
of  disease  of  the  ureteral  orifices,  filled  the  bladder 
with  colored  fluid  and  later  recovered  this  fluid  from 
the  pelvis  of  the  kidney  with  the  ureteral  catheter. 
Sampson  relates  an  interesting  case  in  which  a  patient 
could  actually  feel  fluid  pass  up  into  the  ureters  when 
the  bladder  was  filled  and  a  previously  existing  vesico- 
vaginal fistula  was  closed  by  the  operator's  finger. 
Stricture  of  the  ureter  with  resulting  retention  of 
urine  above  the  stricture  is  undoubtedly  a  cause  of 
ureteral  infection,  the  retained  urine  remaining  in 
situ  long  enough  for  organisms  to  invade  the  tissues, 
a  thing  which  could  not  have  taken  place  had  the 
adventitious  bacteria  been  promptly  washed  down  by 
the  urine  current. 


54  THE    SEQUELAE    OF    GONOERHEA 

Of  all  the  cases  of  gonorrheal  pyonephrosis  reported 
in  literature  and  reviewed  by  the  writer,  none  fulfil 
the  requirements  of  exact  bacteriology,  in  none  has 
the  gonococcus  been  found  in  the  kidney  substance. 
It  can  safely  be  predicted,  that  this  stipulation  will 
soon  be  satisfied :  the  following  cases  illustrate  the 
pathology  of  this  form  of  ascending  renal  infection  :  — 

Cumston  (Univ.  Med.  Mag.  Penn.  Phil.  June,  1899, 
504,)  Cystitis,  following  two  weeks  after  the  onset  of 
acute  gonorrheal  urethritis,  is  complicated  by  chills, 
elevation  of  temperature ;  blood,  bladder  cells,  pus, 
casts,  albumin  and  cells  from  the  renal  pelvis  are 
found  in  the  urine.  A  swelling  in  the  region  of  the 
left  kidney  then  develops,  and  operation  on  this,  five 
weeks  after  the  onset  of  the  urethritis,  releases  1.25 
litres  of  pus.  The  kidney  substance  was  not  destroyed, 
and  the  pus  came  from  the  distended  pelvis.  Unfortu- 
nately no  bacteriological  examination  of  the  pus  was 
made. 

Berg  reports  a  case  of  fatal  endocarditis  (Med.  Eec. 
Iv,  602,)  in  which  a  renal  complication  developed  after 
the  arthritis  and  heart  condition,  probably  from  the  ' 
deposition  of  septic  particles  from  the  blood  stream. 
The  absence  of  cystitis  proved  that  there  could  be  no 
ascending  infection.  Pain  and  tenderness  over  the 
left  kidney  were  explained  by  the  finding  post-mortem 
of  hemorrhagic  spots  in  the  pelvis  of  the  left  kidney 
which  contained  turbid  serum  in  which  were  found 
diplococci  decolorizing  by  Gram's.  Young  also  reports 
a  case  with  practically  the  same  history. 

Our  knowledge  of  the  bacteriology  of  cystitis  in 
women  would  lead  us  to  believe  that  gonorrhea  is  not 
a  frequent  cause  in  this  sex.    In  sixty  cases  studied  by 


IN    BOTH    SEXES.  65 

Brown  bacteriologically  (Jhns.  Hopk.  Hospt.  Rpts.  x, 
48,)  the  B.  coli  com.  was  found  thirty-one  thnes,  Staph, 
albus  seven  times,  T.  B.  six  times,  the  Staph,  aureus 
five  times  and  the  gonococcus  not  at  all.  In  80  cases 
of  infection  of  the  entire  urinary  tract  there  were  no 
findings  of  the  gonococcus,  but  the  B.  coli  was  found 
thirty-eight  times  and  various  staphylococci  eighteen 
times.  In  35  cases  of  cystitis  in  women,  Melchoir 
found  the  gonococcus  but  once ;  and  in  120  cases  col- 
lected from  literature,  Rostoski  found  it  but  three 
times. 

It  has  been  thought  that  ascending  gonococcus  in- 
fection might  be  a  factor  in  the  causation  of  renal 
diabetes.  Luethje  (Munch,  med.  Woch.  Sept.  17, 
1901,)  reports  an  interesting  case  of  this  disease  fol- 
lowing gonorrheal  pyonephrosis. 

Rectal  Gonorrhea. 

Rectal  gonorrhea  may  result  from  auto-infection  or 
from  the  implantation  of  the  cocci  in  any  manner. 
It  differs  from  the  other  complications  of  gonorrheal 
urethritis  in  that  it  is  not  metastatic,  but  is  nearly 
always  from  the  direct  deposition  of  material  in  the 
rectum  or  upon  the  anal  margin.  The  cases  reported 
by  Neisser,  Bumm,  See,  Lang,  Staub,  Frisch  and  others 
do  not  begin  to  indicate  the  frequency  of  the  affection. 
Rectal  gonorrhea  has  been  observed  epidemic  among 
infants  in  an  institution  in  which  the  thermometer 
used  for  taking  rectal  temperatures  was  not  properly 
cleansed  or  protected,  one  case  serving  to  infect  an 
entire  ward.  Weil  observed  30  cases  contracted  in 
this  way.  The  affection  may  be  primary  and  the 
individual  escape  genito-urinary  infection. 


56         THE  SEQUELAE  OF  GONOREHEA 

The  pathology  and  symptoms  are  very  variable,  - 
the  clinical  pictures  varying  from  a  condition  of  ad- 
vanced inflammation  and  sej)sis,  with  profuse  discharge, 
rectal  and  anal  ulcerations,  acuminate  condylomata 
and  ischiorectal  abscess,  to  slight  rectal  folliculitis 
with  but  little  secretion.  The  course  of  the  disease 
also  varies  within  wide  limits,  some  cases  resolving 
within  a  week,  others  being  chronic  and  resistant  to 
treatment.  Untreated  cases  rarely  undergo  spontane- 
ous cure.  The  following  are  the  chief  pathological 
features  :  infiltration  of  the  mucous  membrane,  croup- 
ous exudate  of  pus  and  desquamated  epithelium, 
edema  and  infiltration  of  the  integument  causing  tem- 
porary stenosis  of  the  anus,  acuminate  enlargement  of 
the  rectal  follicles,  necrosis  of  their  apices  leaving 
small  ulcerations  which  may  coalesce,  forming  large 
ulcerative  areas.  The  tissue  involved  is  friable,  granu- 
lating and  spongy,  and  bleeds  freely  on  the  slightest 
abrasion. 

In  a  case  reported  by  Frisch  (Ueber  gonorrhea  rec- 
talis,  AUgem.  med.  Cent.  1902,  No.  x,)  the  gonococcus 
was  found  in  the  rectal  discharges,  ulcerations,  in  the 
glands  and  periglandular  tissues,  and  in  the  perirectal 
tissues  as  far  as  the  same  were  explored  by  incisions. 

The  ease  with  which  therapeutic  agents  may  be 
applied  to  the  rectum  should  make  this  disease  one  of 
short  duration  and  without  sequelae. 

Two  extremely  interesting  cases  of  ulcerative  per- 
foration of  the  rectum  from  gonorrheal  salpingitis 
have  been  reported  by  Otradovec  (Am.  J.  Med.  Sci: 
cxxiv,  665,  April,  1905).  The  first,  a  woman  of  eigh- 
teen years,  presenting  the  physical  signs  of  parame- 
tritis   with    abdominal    swelling   and    obstipation,    is 


IN"    BOTH    SEXES.  57 

operated  on  for  intestinal  obstruction.  At  operation 
the  great  omentum  is  found  fused  into  a  large  mass 
from  which  two  stout  bands  dip  down  into  the  pelvis 
incarcerating  several  loops  of  intestine.  Death  a  few 
hours  after  operation.  Post-mortem  :  the  peritoneum 
is  found  reddened,  there  is  great  meteorism  of  the 
intestinal  loops,  and  behind  the  uterus  a  pus  cavity 
3  cm.  by  6  cm.  is  found  which  perforates  the  rectum 
by  a  pin  hole  aperture  which  is  surrounded  by  a  raised 
irreo'ular  ulceration  1 J  cm.  lonor.  The  tubes  contain 
pus  and  both  tubes  are  infiltrated  with  pus  cells  con- 
taining gonococci. 

In  the  other  case  a  woman  of  forty  six  has  had 
abdominal  pain,  vomiting  and  constipation  for  five 
weeks,  and  is  now  disabled  with  dyspnea  and  swelling 
of  the  body  and  limbs.  Physical  examination  shows 
tumor  of  the  uterus,  bronchitis  and  uncompensated 
aortic  valvular  insufficiency.  Death  occurs  from  pul- 
monary edema  after  a  course  of  symptoms  quite  like 
those  of  any  uncompensated  heart  lesion.  Post- 
mortem the  following  lesions  were  found :  chronic 
deforming  aortic  endocarditis,  multiple  cardiac  myo- 
malacia, fatty  degeneration  of  myocardium,  vegetations 
in  left  ventricle,  bilateral  suppurative  gonorrheal  sal- 
pingitis, circumscribed  ulceration  of  peritoneum  with 
perforation  of  rectum,  dilitation  of  lower  extremity  of 
left  ureter,  stenosis  of  vesical  entrance  of  both  ureters, 
left  pyelitis,  calculi  of  left  kidney. 

Gonorrheal  Invasion  of  the  Skin. 

Gonococci  invade  the  skin  by  direct  implantation 
from  the   contagion   of  overflowing  discharge,  or  in- 


58  THE  SEQUELAE  OF  GONOREHEA 

directly  through  the  cutaneous  lymphatics  or  vessels. 
The  former  is  of  course  the  more  frequent  occurrence. 

The  condition  produced  by  gonorrheal  discharge  is 
usually  of  an  eczematous  or  erythematous  character, 
the  first  symptoms  being  redness  and  swelling  which 
soon  proceed  to  actual  infiltration  and  edema.  If  no 
treatment  be  instituted,  and  if  the  skin  is  not  protected 
from  further  irritation,  there  may  be  exfoliation  of 
the  stratum  corneum  and  desquamation  of  the  strata 
lucidum  and  Malpighii,  leaving  ulcerations  which  are 
extremely  painful  if  in  proximity  to  cutaneous  nerves. 
These  ulcerations  and  the  dermatitis  causing  them  are 
usually  acute  and  quite  amenable  to  treatment,  but  in 
depressed  systemic  states  may  become  chronic  and 
assume  a  pruritic  type,  the  vulvitis  pruriginosa  of 
Sanger.  Rarely,  gonorrheal  ulcers  may  become  serpi- 
ginous and  phagadenic  causing  very  considerable  loss 
of  tissue.  Thalman  (Arch.  f.  Derm.  Syph.  Ixxi,  i, 
1904,  75,)  observed  two  cases  of  this  kind,  in  both  of 
which  typical  gonococci  in  pure  culture  were  found  in 
sections  of  the  tissues.  In  the  first  case  an  ulceration 
of  the  posterior  vaginal  wall  penetrated  the  perivaginal 
tissue  and  caused  a  retro-vaginal  fistula  in  spite  of 
careful  and  persistent  antiseptic  measures.  In  the 
second  case  the  ulceration  of  a  broken-down  buboe 
spread  with  great  rapidity  until  it  involved  the  entire 
inguinal  and  pubic  regions.  Even  the  actual  cautery 
failed  to  inhibit  the  extension  of  the  ulcerative  process, 
but  when  the  true  nature  of  the  case  was  discovered 
by  the  section,  the  employment  of  silver  preparations 
was  followed  by  immediate  improvement. 

Another  case  observed  and  reported  by  Salomon 
and  Blaschko  (Munch,  med.  Woch.  Mch.  3,  1903,)  is 


m   BOTH    SEXES.  59 

illustrative  also  of  the  phagadenic  form  of  gonorrheal 
ulceration  of  the  skin  and  of  the  heljDful  effect  of  silver 
compounds  after  resisting  other  forms  of  treatment. 

Maculae  Gonorrhoicae  are  peculiar  indurated  red 
macules  which  mark  the  entrance  to  the  ducts  of  the 
glands  of  Bartholin  and  are  due  to  gonorrheal  inflam- 
mation of  these  glands.  Rarely,  they  appear  in 
inflammation  from  other  bacteria. 

Petnphigus  Bullosus  of  the  new-born  has  been  ob- 
served by  Krakow  (Gaz.  Lekarska,  1894,  632,)  in  a 
case  of  gonorrheal  ophthalmia,  the  mother  having 
gonorrheal  puerperal  sepsis  and  arthritis. 

Pruritus.  —  Gonorrheal  arthritis  may  be  accom- 
panied by  intense  pruritus  over  the  affected  joints, 
as  has  been  observed  by  Domenici  (Gaz.  Ospedale, 
Mch.  1,  1903).  In  this  case  the  pruritus  was  not 
helped  by  any  method  of  treatment,  but  ceased  sud- 
denly upon  improA^ement  in  the  arthritis. 

Urticaria  over  the  whole  body  has  been  observed 
by  Orlipsky  (Munch,  med.  Woch.  Oct.  7,  1902,)  who 
describes  it  as  vanishing  with  the  cessation  of  the 
gonorrhea  and  not  differing  in  any  from  urticaria  from 
other  causes. 

Diffuse  Erythemas  and  Exanthems  are  occasionally 
observed  during  gonorrhea  of  children.  Ordinarily 
there  is  a  bluish  or  red  rash  with  local  heat  of  the 
skin  which  is  evanescent,  but  which  in  severe  cases 
may  go  on  to  furunculosis  or  suppuration.    These  may 


60         THE  SEQUELAE  OF  GONOKRHEA 

be  characterized  also  by  small  papules  which  soon 
change  into  vesicles  containing  either  clear  or  turbid 
serum  or  pus,  in  which  the  gonococcus  is  usually 
found. 

An  interesting  condition  of  the  nails  caused  by 
gonorrhea  has  been  observed  by  Vidal,  Jeanshue, 
Stanislowski,  Krotoszyner  and  others.  A  line  of  de- 
marcation appears  between  the  matrix  and  body  of 
the  nail,  the  outer  half  formed  by  this  margin  turns 
grayish-white,  the  border  becomes  frayed  and  ragged, 
there  is  progressive  marginal  lifting  of  the  nail  until 
it  falls  off.  This  process  is  sometimes  painful  but  is 
usually  painless.  Swelling  and  redness  of  the  finger 
tip  may  or  may  not  be  present,  and  regeneration  of 
the  nail  is  exceedingly  slow. 

Herpes  Gestationes. — Touton  (iv  Congres  de  la  Soc. 
Allemande  de  Dermat.  Breslau,  1904,)  has  found  an 
organism  conforming  with  the  morphological  and 
staining  qualities  of  the  gonococcus  in  the  lesions  of 
a  case  of  herpes. 

Another  rare  cutaneous  manifestation  of  gonorrhea 
has  been  observed  by  Baermann  (Arch.  d.  Darm.  u. 
Syph.  Ixi,  Heft.  3,)  in  two  cases  of  gonorrheal  pyemia. 
In  both  cases  the  lesions  were  polymorphous  and  were 
either  disseminated  over  the  entire  body  or  else  were 
limited  to  the  hands  and  feet.  In  the  former  case  the 
appearance  of  vesicles  is  followed  by  the  formation  of 
crusts  and  scales  which  are  laminated,  cone-shaped, 
and  firmly  adherent  to  a  moist,  red,  papillomatous 
base.  In  lesions  of  the  hands  and  feet  there  is 
thickening  of  the  stratum  corneum  of  the  palms  and 
soles  and  upon  these  areas  there  are  discrete  or  con- 


IN    BOTH    SEXES.  61 

fluent  conical  protuberances  which  are  either  smooth 
or  tissured.  The  nails  become  brittle  and  may  fall  off, 
leaving  the  oozing  surface  of  the  underlying  epider- 
mis. These  lesions  frequently  occur  in  j^lacques  on 
the  lower  extremities,  particularly  on  those  atrophied 
by  joint  disease.  Microscopically  there  is  prolifera- 
tion of  the  papillary  layer,  induration  of  the  vessels 
which  are  surrounded  by  an  area  of  leucocytic  infiltra- 
tion, migratory  cells  are  found  in  the  deep  layers  of 
the  epidermis,  and  the  horny  masses  show  incompletely 
cornified  parakeratotic  cells,  their  nuclei  being  still 
visible. 

Gonorrheal  Affections  of  the  Nervous  System. 

Gonorrhea  affects  the  nervous  system  by  the  direct 
local  action  of  the  cocci  and  by  the  toxin  circulating 
in  the  blood  stream.  The  former  results  in  meningitis, 
myelitis,  and  perhaps  neuritis ;  the  later  in  neuralgia, 
neuritis,  neurasthenia  and  mental  states. 

After  inoculating  animals  with  gonotoxin,  Molts- 
chanoff  found  deo;enerative  lesions  resemblino;  tabes  in 
the  posterior  columns  of  the  spinal  cord. 

Neuralgia  is  a  comparatively  common  accompani- 
ment of  urethritis  and  arthritis  and  occurs  most  fre- 
quently in  the  sciatic  nerves.  Kalabin  (Cent.  f.  Gyn. 
1903,  xxvii,)  observed  two  cases  of  sciatica  and  inter- 
costal neuralgia  in  women  who  became  infected  shortly 
after  marriage.  In  both  of  these  cases  nerve  pain 
began  two  weeks  after  the  beginning  of  the  discharge 
and  ceased  with  improvement  in  the  local  condition  a 
month  later.  This  observer,  from  a  thorough  study 
of  the  subject,  is  convinced  that  there  is  a  direct  rela- 


62  THE    SEQUELAE    OF    GOISTORRHEA 

tion  betv/een  the  two  and  suggests  the  possibiUty  of 
irritation  of  the  brain  by  the  toxin. 

Neuritis.  —  As  might  be  supposed,  a  nerve  travers- 
ing a  tissue  mass  infiltrated  by  coccus-bearing  cells 
would  h^  likely  to  participate  in  the  inflammatory 
process  and  exhibit  the  usual  symptoms  of  neuritis. 
Keinbock  (Samm.  klin.  Yort.  cccxv.)  observed  such  a 
case  in  which  there  was  infiltration  of  the  region  of 
the  olecranon,  arthritis  of  the  shoulder  joint  with 
crepitation,  and  atrophic  changes  in  the  skin  and 
naiiS. 

Panas  (La  Sera.  Med.  1890,)  observed  a  case  in 
which  there  was  inflammation  of  the  cranial  nerves 
with  transient  deafness,  diplopia,  and  the  usual  signs 
of  optic  neuritis. 

Tambourer  (Soc.  de  Neuropath,  et  d'Alien.  de 
Moscou.  21  Jan.  1894,)  observed  an  instructive  case  of 
multiple  gonorrheal  arthritis  and  gonorrheal  phlebitis 
in  which  lesions  of  the  intervertebral  articulations 
caused  pressure  on  the  vertebral  nerves.  Death  re- 
sulted from  cerebral  embolism  secondary  to  the  gonor- 
rheal thrombo-phlebitis. 

Pitres  (Accidents  cerebraux  dans  le  cours  de  la  Blen. 
Rev.  Neurolog.  1894,  441,)  reports  two  similar  cases  of 
cerebral  softening  following  gonorrhea. 

Gljam  (Lancet,  Sept.  27,  1902,)  reports  and  discusses 
two  cases  of  paralysis  of  gonorrheal  origin,  one  of 
ascending  paralysis  with  peripheral  neuritis,  the  other 
of  pseudo-tabes.  Both  of  these  recovered.  Raymond 
(Prog.  Med.  27  Juil.  1901,)  reports  cases  of  ascending 
paralysis  and  polyneuritis.  Gull  (Trans.  New  Syden- 
ham  Soc.   1880,)  reports   three    cases   of   myelitis   of 


IN    BOTH    SEXES.  63 

gonorrheal  origin,  and  Charcot  (Diseases  of  Nervous 
System,  1880,)  includes  gonorrhea  as  one  of  the  causes 
of  degenerations  of  the  spinal  cord. 

Meningitis  of  gonorrheal  origin  has  been  observed 
by  Panas  and  was  characterized  by  elevation  of  tem- 
perature, intense  headache  and  eye  symptoms  ending 
in  optic  atrophy.  In  a  case  of  Jullien  (Trans.  French 
Assn.  G.  U.  Surgeons.  Oct.  21, 1897,)  recovery  followed 
in  the  case  of  a  young  girl  in  whom  gonorrheal  vagin- 
itis was  complicated  by  teno-synovitis,  hygroma,  myo- 
sitis, nephritis  and  meningitis.  Skin  sj^mptoms  con- 
sisting of  rose-colored  lenticular  spots  appeared  during 
the  course  of  the  meningitis.  Von  Leyden  observed 
a  case  due  indirectly  to  gonorrhea.  Primary  gonor- 
rheal urethritis  was  followed  by  acute  gonorrheal 
cystitis  which  became  chronic.  Paraphlegia  and  death 
resulted  from  the  urinary  infection,  and  autopsy 
showed  degeneration  of  the  posterior  columns  of  the 
cord.     (Zeit.  f.  klin.  Med.  1892,  xxi,  5.) 

But  of  far  greater  importance  than  these  is  a  case 
observed  by  Furbringer  (Deut.  Med.  Woch.  1896, 
No.  27,)  in  which  the  lumbar  puncture  of  a  case  of 
cerebro-spinal  meningitis  showed  fluid  containing  typi- 
cal gonococci,  as  did  the  exudate  on  the  meninges 
observed  post-mortem.  Through  the  courtesy  of  a 
scientific  layman  the  writer  is  able  to  give  brief  facts 
of  two  cases  of  gonorrheal  paralysis.  The  first,  a  man 
of  thirty-two  has  gonorrheal  arthritis  and  synovitis  of 
both  knees  and  ankles,  —  no  operation.  Three  years 
after  the  initial  urethritis,  paraphlegia  develops.  In 
the  other  case,  a  man  of  thirty  has  gonorrheal  syno- 
vitis of  one  knee  which  is  followed  by  sensory  paralysis 


64         THE  SEQUELAE  OF  GONORRHEA 

of  the  affected  leg  which  improves  only  after  a  pro- 
lono;ed  course  of  treatment. 


Affecting  the  Mental  System. 

The  numerous  mental  complications  of  gonorrhea 
may  be  divided  into  two  classes,  —  those  due  to  the 
moral  and  social  circumstances  of  venereal  disease, 
and  those  resulting  from  the  anemia,  systemic  reduc- 
tions caused  b}^  prolonged  suppuration,  and  from  the 
irritation  of  the  toxin  on  the  brain.  The  probability 
of  nervous  and  mental  disorders  and  the  reasons 
therefor  in  cases  of  gonorrhea  insontium  are  too 
apparent  to  require  special  discussion.  In  the  latter 
class,  the  induced  anemia  together  with  gonotoxin 
may  act  as  a  precipitating  force  upon  a  mental  pre- 
disposition, just  as  bacterial  diseases  of  other  kinds, 
as  weir  as  the  complicated  poisons  of  auto-intoxication, 
may  be  the  final  forces  which  overtax  the  already 
burdened  system. 

In  twenty-two  cases  of  hebephrenia  studied  by 
Venturi,  twelve  had  gonorrhea,  which  he  considered 
responsible  for  the  following  phenomena,  —  stupor, 
hallucinations,  somnolence  and  hypersensitiveness :  of 
objective  symptoms,  —  delirium,  attempts  at  suicide, 
choreiform  movements,  maniacal  excitement,  increased 
skin  reflexes,  cataleptic  and  catatonic  states.  These 
symptoms  for  the  most  part  disappeared  with  the 
venereal  disorder.  The  writer  has  recently  observed 
a  case  of  nocturnal  delirium  complicating  acute  gonor- 
rheal urethritis  which  was  characterized  by  slight  ele- 
vation of  temperature,  somnolence  during  the  day, 
but  throughout  a  marked  elevation  of  pulse  tension. 


IN    UOTII    SEXES.  65 

Widiil  and  dift'erential  white  count  negative,  —  im- 
provement in  the  mental  condition  with  urethral 
treatment. 

Neurasthenia,  particularly  of  the  sexual  type,  and 
hypochondriasis  are  also  frequently  observed.  Kro- 
toszyner  (Trans.  San  Fran.  Co.  Med.  Soc.  Dec.  11, 
1900,)  in  a  large  experience  of  foreign  genito-urinary 
wards  found  that  00%  to  70%  of  all  cases  of  gonorrhea 
presented  such  symptoms. 

Gonorrheal  Affections  of  the  Pleurae  and  Lungs. 

The  occurrence  of  pleurisy  during  inflammation  of 
other  organs  has  been  often  noted.  Lapeyre  (Essai 
sur  les  complications  perihepatique  et  pleurales  de 
I'Appendicite,  Rev.  de  Chir.  xxii,  508,)  quotes  some 
thirty  cases  and  Piart  (These  de  Paris,  1896,)  also  has 
discussed  the  subject.  The  blood  supply  of  the  pleurae 
is  rich.  The  visceral  pleura  is  supplied  by  the  bron- 
chial artery,  the  diaphragmatic  and  costal  pleurae  by 
the  diaphragmatic  and  intercostal  arteries  and  the 
mediastinal  pleura  by  the  superior  diaphragmatic,  the 
internal  mammary,  the  bronchial  and  the  superior 
mediastinal  arteries.  It  is  to  be  believed  that  gonor- 
rheal particles  reach  the  pleurae  and  lungs  through 
the  circulation  and  not  through  inspired  floating  matter 
in  the  air,  and  that  these  cases  are  local  manifestations 
of  a  general  systemic  gonorrheal  infection. 

Bordoni  Uffreduzzi  (Deut.  med.  Woch.  31  Mai,  1894, 
484,)  reports  two  cases  of  gonorrheal  pleurisy,  one  in 
a  woman  with  arthritis  showing  gonococci  in  the  pus 
from  the  joints ;  another  in  a  girl  of  eleven  years,  in 
which  polyarthritis  followed  an  old  double  pleurisy. 


66  THE  SEQUELAE  OF  GONORRHEA 

the  fluid  of  which  showed  gonococci  on  aspiration. 
Following  these  there  was  endo-pericarditis  which 
subsided  and  which  were  undoubtedly  of  gonorrheal 
origin. 

Chiaiso  et  Irnardi  (Giornale  della  R.  Acad,  di  Med. 
di  Tor.  Fev.  1894,  93,)  observed  a  case  in  a  girl  of  ten 
with  gonorrheal  rheumatism  of  the  feet,  knees,  right 
shoulder  and  wrists.  A  systolic  mitral  murmur  ap- 
peared and  persisted.  The  puncture  of  a  right  pleural 
effusion  showed  fluid  containing  the  gonococcus. 

But  pleurisy  may  result  from  supposedly  ordinary 
cases  of  gonorrhea  as  is  shown  by  a  case  of  Ahman 
(Arch.  f.  Dermat.  u.  Syph.  1897,  xxix,  323,)  in  which 
the  urethra  of  a  healthy  man  was  inoculated  with  the 
culture  of  the  fifth  generation  of  cocci  from  a  case. 
In  spite  of  every  precaution  cystitis,  epididymitis, 
synovitis  and  pleurisy  resulted. 

Pneumonitis. 

Schlagenhaufer  {op.  cit.),  in  an  interesting  case  of 
gonorrheal  ophthalmia,  arthritis  and  phlegmon  com- 
pUcated  with  pneumonia,  found  typical  gonococci, 
together  with  the  streptococcus  pyogenes  and  the 
diplococcus  pneumoniae  in  the  S]3utum.  Post-mortem 
the  pulmonary  alveoli  were  found  to  be  distended 
with  exudate  composed  of  red  blood  corpuscles,  epi- 
thelial cells  and  pus  corpuscles  containing  gonococci. 

In  another  case  observed  by  Krause  (oj).  cit.),  a  case 
of  acute  gonorrhea  became  complicated  by  endocar- 
ditis, pleurisy  with  effusion,  and  five  weeks  after  the 
occurrence  of  the  initial  symptoms  showed  the  gono- 
coccus in  the  blood  by  culture.     Pos1>mortem  tliis  case 


IX    BOTH    SEXES.  67 

fehowed  acute  fibrinous  pericarditis,  gonorrheal  ulcera- 
tive aortic  endocarditis,  fatty  degeneration  of  the 
myocardium,  pleurisy  with  effusion,  ascites  and  lobar 
pneumonia.  The  gonococcus  was  found  in  pure  culture 
in  the  puhnonary  alveoli. 

Another  case  of  gonococcus  pneumonia  is  reported 
by  Bressel  (Munch,  med.  Woch.  Mch.  31,  1903,)  in 
which  a  patient  with  acute  gonorrheal  urethritis  devel- 
oped pneumonia,  the  sputum  showing  the  characteristic 
intra-cellular  organisms,  and  the  peripheral  blood  giving 
a  positive  culture  of  the  gonococcus.  This  interesting 
case  made  a  good  recovery. 

Another  unusual  case  of  gonorrheal  invasion  of  the 
respiratory  mucous  membrane  is  of  interest.  (Kimball, 
Med.  Rec.  Ixiv,  765.)  An  infant  of  two  and  one-half 
months  is  admitted  to  the  Babies'  Hospital  as  a  case 
of  malnutrition.  Father  consumptive,  mother  well, 
child  well  for  first  month  of  hfe ;  nursed  but  two 
weeks ;  no  ophthalmia,  but  considerable  thrush  in  the 
mouth.  Digestion  and  stools  normal.  There  is  pro- 
gressive involvement  of  the  joints,  —  first  the  left 
wrist,  then  both  ankles,  right  knee  and  httle  finger, 
with  fluctuation  in  all  of  these  joints.  The  tempera- 
tm'e  is  under  102°  F.  until  the  last  three  days  of  life, 
and  during  these  is  normal.  Gonococcus  in  pure  cul- 
ture in  the  pus  aspirated  ante-mortem.  Autopsy 
showed  small  abscesses  under  the  scalp,  under  the  skin 
over  the  chest,  and  between  the  larynx  and  the  hyoid 
bone.  There  is  pus  in  all  the  joints  involved,  and  on 
incising  the  larynx  pus  containing  gonococci  is  found 
in  the  posterior  wall  between  the  mucous  membrane 
and  the  thyroid  cartilages.  Incipient  broncho  pneu- 
monia.    No  gonococci  in  the  eyes  or  urethra. 


68  THE  SEQUELAE  OF  GONORRHEA 

Gonorrheal  Endocarditis. 

Gonorrheal  endocarditis  probably  results  from  the 
presence  of  gonococci  in  the  blood  stream  and  their 
engraftment  upon  the  cardiac  valves,  especially  upon 
the  lesions  of  an  old  endocarditis,  by  the  impact  of 
the  valves.  Once  established,  an  infected  valve  acts 
as  a  point  of  distribution  for  the  infection  of  the  whole 
system. 

As  early  as  1854  Brandes  (Arch.  gen.  de  Med.  xciv, 
257,)  called  attention  to  this  complication,  and  in  1872 
Lacassagne  (Arch.  gen.  de  Med.  cxxix,  15,)  stated  that 
gonorrhea  might  attack  any  serous  surface,  and  that 
gonorrheal  affections  of  the  peri-endo  and  myocardium 
were  not  infrequent.  In  1872  Martin  (Rev.  Med.  de 
la  Suisse  Eomnade,  1872,  ii,  308,)  observed  a  case  of 
gonorrhea  complicated  by  suppurative  prostatitis,  cys- 
titis, ulcerative  endocarditis,  abscesses  of  the  myocar- 
dium and  metastatic  abscesses  of  the  kidneys.  Char- 
acteristic diplococci  were  found.  His  (Dent.  med. 
Woch.  xxix,  1892,  993,)  Leyden  (Zeit.  f.  klin.  Med. 
xxi,  607,)  Winderberg  (Fest.  Jub.  der  Vereins  deut. 
Aertze,  San  Francisco,  1894,)  Michaehs  (Zeit.  f.  klin. 
Med.  xxix,  556,)  Lartigan  (Am.  J.  Med.  Sci.  cxxi,  52,) 
also  have  reported  interesting  cases  in  which  the 
gonococcus  was  found  on  the  heart  valves.  In  fifty- 
nine  cases  of  malignant  endocarditis  observed  by 
Jackson  (Bost.  City  Hospt.  Rpts.  xi,  67,)  three  were 
gonorrheal. 

For  brevity's  sake  it  must  be  said  that  endocarditis 
of  gonorrheal  origin  does  not  differ  symptomatically 
from  that  caused  by  other  organisms.  The  presence 
of  an  active  or   even  subacute  gonorrheal  urethritis. 


IN    BOTH    SEXES.  69 

gonorrheal  prostatitis  or  prostatic  al)scess,  and  especi- 
ally a  gonorrheal  arthritis, — would  warrant  the  predic- 
tion that  an  endocarditis,  more  especially  of  the  ulcera- 
tive or  malignant  form,  was  gonorrheal  in  its  nature. 

Pathology.  —  This  varies  with  different  cases,  — 
there  may  be  round  or  irregular  ulcerations  which 
are  shallow,  surrounded  by  a  ring  of  pearly  lustre, 
varying  in  size  from  minute  punctate  spots  to  large 
areas  covering  one  or  more  valves.  If  these  are  deep 
enough  the  valves  are  perforated,  or  the  endocardium 
may  be  undermined.  In  the  vegetative  form  pedun- 
culated, pyramidal  or  verrucose  masses  proceed  from 
the  valve,  which  show  a  microscopic  structure  of  con- 
nective tissue  reticulum  filled  with  blood  platelets  and 
leucocytes.  Further  particulars  are  readily  found  in 
the  abundant  literature  on  the  subject,  —  and  in  dis- 
cussion of  the  pathology  of  gonorrheal  endocarditis  in 
particular,  the  attention  is  invited  to  the  following 
condensed  autopsy  reports. 

Thayer  &  Blumer.  (Jhns.  Hopk.  Hospf.  Bull,  vii. 
No.  61,  67.)  A  woman  of  thirty-four,  short  of  breath 
for  four  years,  five  months  ago  had  fugitive  pains. 
Malaise  increasing  into  prostration,  herpes  on. lower 
lip,  thirst,  anorexia,  chills  and  irregular  temperature, 
are  the  chief  symptoms.  Heart  shows  presystolic 
murmur  followed  by  a  blowing  systolic  sound  at  the 
mitral  area  transmitted  into  the  axilla.  Leucocytosis 
of  12,000.  Post-mortem,  —  vegetations  consisting  of 
red  pedunculated  mass  and  red  blood  corpuscles 
measuring  2  by  3  cm.  from  mitral  valve :  valve  eroded 
under  the  vegetations.  Microscopically  the  valves 
show    subacute    endocarditis,  —  infiltration    of    valve 


70  THE    SEQUELAE    OF    GONORRHEA 

substance  with  large  numbers  of  polymorphonuclear  leu- 
cocytes and  a  few  round  cells  and  mastzellen  through- 
out the  inflammatory  areas.  Gonococci  are  found  in 
small  numbers  in  sections,  but  in  large  numbers  on 
the  margins  of  the  valvular  growths.  Smears  from 
the  valves  show  the  invasion  of  the  nuclei  as  well  as 
the  protoplasm  of  the  pus  corpuscles  by  the  gonococci, 
—  a  very  rare  condition  never  observed  by  the  writer. 
Blood  cultures  were  taken  three  times  during  life  and 
were  twice  found  in  pure  culture  and  growing  readily 
on  blood  serum. 

Case  of  gonorrheal  endo-myo-pericarditis.  Council- 
man. (Bost.  City  Hospt.  Rpts.  Series  v,  55.)  Man 
noticed  urethral  discharge  four  weeks  before  entrance 
to  hospital;  ten  days  later  left  knee  becomes  involved 
and  three  days  later  the  other;  the  inflammation  then 
rapidly  extends  to  the  ankles,  fingers  and  shoulders. 
Slight  pain  in  the  chest,  —  examination  shows  slight 
increase  in  the  area  of  heart  dulness  but  no  friction 
sounds  or  cardiac  murmur,  and  on  the  day  before  the 
patient's  death  this  pain  became  so  severe  that  leeches 
were  applied.  Sudden  death  without  premonitory 
symptoms,  the  pulse  having  been  below  110°,  and  the 
temperature  not  having  arisen  above  99.5°  F.  Total 
duration  of  illness  about  5  weeks. 

Post-mortem.  —  Lower  portions  of  both  lungs  ede- 
matous; both  lungs  free  from  adhesions  but  com- 
pressed by  the  pericardial  sac  which  is  enormously 
distended,  containing  800  cc.  of  hemorrhagic  exudate 
with  masses  of  clotted  blood.  Myocardium  of  left 
ventricle  firm  and  of  waxy  color  resembling  amyloid. 
Near  endocardium  at  the  bases  of  the  papillary  muscles 


IN  BOTH  SEXES.  71 

the  tissue  has  a  translucent  and  gelatinous  appearance, 
and  this  tissue  extends  into  the  myocardium  for  a  con- 
siderable distance.  This  condition  of  the  myocardium 
is  confined  almost  entirely  to  the  left  ventricle.  On 
the  anterior  surface  of  the  left  auricle  there  is  an  area 
2  by  3.5  cm.  where  the  muscular  tissue  is  changed 
into  a  pale  opaque  material  which  in  some  places  is 
soft  and  almost  l^roken  down.  The  follicles  of  the  in- 
testines are  enlarged  and  hyperemic  and  in  some  places 
appear  like  small  polypi :  all  mesenteric  lymph  glands 
are  enlarged.  The  right  knee  joint  is  greatly  dis- 
tended and  on  section  100  cc.  of  gelatinous,  stringy 
and  rather  transparent  pus  escapes.  The  muscles 
above  the  joint  show  diffuse  purulent  infiltration. 
The  s)Tiovial  membrane  of  the  joint  is  swollen  and 
intensely  congested,  and  projecting  into  the  joint  are 
fungoid  masses  presenting  the  appearances  of  tuber- 
cular granulations.  Sections  of  the  heart  showed  the 
most  intense  pericarditis,  the  pericardium  being  every- 
where thickened,  in  some  places  to  3  mm.  In  the 
thickened  pericardium  there  are  numerous  widely 
dilated  blood  vessels,  from  which  the  blood  in  the  sac 
probably  proceeded,  and  the  tissue  is  loose  and  infil- 
trated with  pus  cells.  In  the  myocardium  all  grades 
of  change  from  infiltration  to  necrosis  and  suppuration 
involving  the  entire  thickness  of  the  heart  wall  can  be 
observed.  Gonococci  were  found  in  the  fluids  from 
the  urethra,  the  seminal  ducts,  the  knee  joints,  and  in 
sections  of  the  myocardium,  the  jDcricardium,  and  the 
knee  joints. 

Rendu  &  Halle  (Bull,  et  Mem.  du  Soc.  Med.  des 
Hop,  de  Paris,  1897,  xiv,  1325,)  report  an  interesting 
case  of  gonorrheal  endocarditis  in  which  the  coccus 


72  THE  SEQUELAE  OF  GONOKEHEA 

was  found  in  pure  culture  in  the  endometrium  during 
life  and  from  the  elbow  joint  and  heart  lesion  post- 
mortem. 

Gonorrhea  may  be  the  indirect  cause  of  endo-myo- 
carditis  as  is  illustrated  by  the  following  case  of 
Weckerle.  (Munch,  med.  Woch.  1886,  Nos.  32  to  36.) 
Robust  woman  of  twenty-one  years  :  gonorrhea,  right 
inguinal  adenitis,  articular  symptoms  resembling  acute 
articular  rheumatism.  Two  weeks  later  systolic  mur- 
mur develops  at  apex,  right-sided  pleurisy  with  dilata- 
tion of  the  right  heart  and  acute  nephritis  leads  to  her 
death. 

Post-^  tor  tern,.  —  Ulcerative  jyuhnonary  endocarditis, 
dilatation  of  the  right  heart,  atrophic  myocarditis,  em- 
bolism of  arteries  of  inferior  lobes  of  both  lungs,  right 
pleurisy,  parenchymatous  nephritis.  The  myocardium 
kidneys  and  the  vegetations  on  the  valves  showed 
cocci  in  chains  and  masses  which  were  considered  by 
Finger  as  non-gonorrheal.  Quite  likely  this  case  is 
representative  of  a  considerable  number  of  cases  of 
malignant  endocarditis  in  which  the  gonococcus  was 
not  found  post-mortem,  but  which  owed  their  existence 
to  bacteria  admitted  with  tlie  gonococcus  at  the  time 
of  original  infection  or  gaining  admission  through 
gonorrheal  lesions. 


& 


Phlebitis. 


Gonococci  find  their  way  to  the  intima  of  blood 
vessels  by  direct  deposition  from  the  blood  stream, 
and  by  penetration  of  the  walls  from  surrounding 
infected  tissue.  In  consideration  of  the  traumatism 
which  we  know  occasionally  accompanies  instrumenta- 


IN    BOTH    SEXES.  73 

tion  of  the  urethra,  it  is  not  surprising  that  bacteria 
are  forced  through  vessel  tunics  and  set  up  a  vascu- 
litis. Gonorrheal  phlebitis  is  not  common,  —  but 
twenty-six  cases  are  thus  far  available.  As  might  be 
supposed  phlebitis  is  a  feature  of  the  complications  of 
gonorrhea  rather  than  of  the  primary  urethritis  itself. 
Heller's  case  (Berl.  klin.  Woch.  No.  28,  1904,  610,) 
was  caused  by  prostatitis  and  severe  urethrocystitis : 
cases  recorded  by  Batut  (Gaz.  hebd.  1900,  No.  54,) 
Stordeur  (Prog.  med.  Belg.  Juni,  1900,)  Tedenat, 
Fouilloux,  Martel  and  Sasserath  (Inaug.  Dis.  12  Marz, 
1904,)  were  secondary  to  epididymitis.  A  case  re- 
ported by  French-Banham  (Lancet,  Oct.  16,  1886,) 
had  gonorrheal  pleurisy,  prostatitis  and  pyelitis,  and 
one  of  Martel  (These  Paris,  1887,)  had  gonorrheal 
erythema  nodosum. 

In  this  series  of  twenty-six  cases  the  phlebitis  was 
right-sided  sixteen  times,  left  in  fifteen,  and  in  thirteen 
the  side  was  not  specified.  Of  these  forty-four  involve- 
ments the  distribution  was  among  the  following  veins  : 
—  common  iliac,  femoral,  popliteal,  frofunda  crurae, 
internal  and  posterior  saphenous,  superficial  abdominal, 
vaginal,  dorsal  of  penis,  corpora  cavernosa,  prostatic 
and  vesical  plexus,  pampiniform  plexus,  upper  arm 
forearm.  That  gonorrheal  phlebitis  is  quite  as  serious 
as  that  caused  by  other  organisms,  appears  in  that  in 
one  of  these  cases  amputation  of  the  thigh  for  pop- 
liteal and  femoral  phlebitis  was  necessary :  in  another 
fatal  pulmonary  embolism  ensued ;  in  another  general 
pyemia  with  death  resulted ;  in  one  thrombosis  of  the 
cavernous,  prostatic  and  vesical  plexuses  occurred; 
and  in  one  gangrene  of  the  penis  from  thrombosis  of 
the  veins  of  the  corpus  cavernosus  took  place. 


74  THE  SEQUELAE  OF  GONOEEHEA 

Additional  features  of  gonorrheal  phlebitis  will  be 
noted  in  the  discussion  of  general  systemic  infection. 

Arteritis. 

Arterial  thrombosis  of  distinctly  gonorrheal  origin 
is  so  uncommon  that  a  brief  abstract  of  a  case  of 
Moore  is  given.  (Lancet,  Dec.  19,  1903.)  The  post- 
mortem of  a  case  of  dry  gangrene  of  both  legs  follow- 
ing acute  urethritis  showed  a  firm  reddish-gray  coagu- 
lum  filling  the  aorta  below  the  renal  branches,  — 
another  of  the  left  renal  artery  extending  into  the 
di^dsions  of  the  hilum,  and  another  extending  from  the 
pelvic  brim  down  the  external  iliac  to  the  common 
femoral  artery.  There  was  also  necrosis  of  the  left 
kidney  caused  by  the  thrombosis  of  the  renal  artery. 
Histological  examination  of  the  thrombus  showed 
gonococci  in  its  substance  and  in  some  portions  of  the 
vessel  a  complete  disappearance  of  the  intima.  Besides 
the  urethritis  two  tiny  foci  of  suppuration  were  found 
in  the  prostate  gland,  and  it  is  to  be  supposed  that 
these  contributed  the  infectious  particles  which  caused 
the  thrombosis. 

General  Gonorrheal  Infection. 

The  following  features  of  general  gonorrheal  infec- 
tion have  already  been  discussed  under  various  head- 
ings :  —  endocarditis,  a  cause  as  well  as  a  result  of 
general  infection ;  blood  cultures  in  arthritis  and 
under  the  bacteriology  of  the  gonococcus;  phlebitis 
and  prostatic  abscess  causing  pyemia ;  instrumentation 
as  a  means  of  admittins;  bacteria  to  the  circulation. 
In   addition  to   these,  however,  several   cases   are   of 


IN   BOTH    SEXES.  75 

great  significance,  and  serve  to  illustrate  not  only  the 
direct  but  the  indirect  results  of  gonorrheal  infection, 
{.  e.,  mixed  infections  due  to  gonorrheal  urethritis. 

Halle  (Ann.  de  Gyn.  Sept.  1899,)  reports  a  case  of  a 
woman  who  acquires  gonorrhea  which  assumes  the 
hemorrhagic  form  of  metritis.  Suppurative  peri- 
arthritis of  the  elbow  then  ensues  and  the  patient 
advances  into  a  state  of  hectic  fever  with  rapidly 
developing  gonorrheal  aortic  endocarditis.  This  as- 
sumes the  malignant  form  and  is  rapidly  fatal.  Post- 
mortem, —  the  gonococcus  is  found  in  the  uterus,  in 
the  periarthritic  pus  and  on  the  aortic  vegetations. 

General  pyemia  with  multiple  foci  of  suppuration  is 
very  well  illustrated  by  the  unusual  case  of  Finger 
(Arch.  f.  Derm.  u.  Syph.  Wien.  u.  Leip.  xxviii,  1894.) 
A  child  with  gonorrheal  ophthalmia  develops  arthritis, 
in  which  the  cocci  are  found  in  pure  culture,  and  this 
is  followed  by  extensive  phlegmonous  inflammation  of 
the  neck  and  mediastinum  causing  death.  Post-mortem, 
—  gonococci  are  found  in  the  right  articulation  of  the 
jaw,  in  an  area  of  perichondritis  about  a  sterno-costal 
articulation,  gonococci  and  streptococci  and  in  a  peri- 
articular abscess  of  the  left  thigh,  and  streptococci 
alone  in  the  left  articulation  of  the  jaw  and  in  the 
phlegmons  of  the  neck  and  mediastinum. 

General  infection  and  death  may  follow  with  start- 
ling rapidity  as  has  been  observed  by  Osier  (Practise, 
256.)  Severe  chills  gave  place  to  high  temperature, 
unconsciousness  and  profound  toxemia.  Death  oc- 
curred ten  days  after  the  first  appearance  of  the 
gonorrheal  urethritis.  Post-mortem  showed  acute 
gonorrheal  urethritis,  a  small  prostatic  abscess  3  cm. 
in  diameter  and  a  peculiar  tarry  condition  of  the  blood. 


76  THE    SEQUELAE    OF    GONORRHEA 

Ullmann  observed  five  cases  of  gonorrheal  sepsis,  all 
fatal  and  all  but  one  with  prostatic  abscesses.  (Deut. 
Arch.  f.  klin.  Med.  Ixix,  309.)  i.  Untreated  gonorrhea 
for  several  months,  prostatic  abscess  showing  no  symp- 
toms and  being  unrecognized  during  life,  septic  throm- 
bosis of  prostatic  plexus  and  general  pyemia  from 
this.  ii.  General  infection,  the  symptoms  resembling 
typhoid,  staphylococcus  abscess  of  the  prostate  of 
gonorrheal  origin,  iii.  Gonorrhea  followed  by  peri- 
orchitic  and  prostatic  abscesses,  the  latter  not  recog- 
nized during  life.  iv.  Prostatic  abscess  followed  by 
cystitis  and  pyemia,  v.  Gonorrheal  arthritis  followed 
by  gonorrheal  pericarditis  and  ulcerative  endocarditis 
and  general  sepsis. 

But  the  finding  of  the  gonococcus  in  the  blood  does 
not  necessarily  mean  that  death  will  result,  for  Krause 
(Berl.  klin.  Woch.  May  9,  1904,)  observed  such  a  case 
in  a  woman  who  became  infected  through  a  laceration 
of  the  perineum  and  developed  double  gonorrheal 
pyosalpinx.  General  infection  in  this  case  was  evi- 
denced by  enlargement  of  the  spleen,  pain  and  swel- 
ling of  the  knee,  along  the  course  of  several  ribs,  and 
b}^  a  positive  culture  from  the  blood. 

Another  interesting  case  of  general  infection  with 
recovery  was  observed  by  Breton  (J.  des  Mai.  Cut.  et 
Syph,  1894.)  In  a  young  man  of  twenty-one,  enlarge- 
ment of  the  spleen  and  inguinal  glands  announces 
the  general  character  of  the  infection :  this  is  fol- 
lowed by  acute  endocarditis,  multiple  periarthritis  and 
a  polymorphous  erythema  which  is  first  macular,  then 
papular  and  then  followed  by  the  formation  of  vesicles 
containing  gonococci. 


IN    BOTH    SEXES.  77 

Another  case  of  neglected  gonorrhea  is  described  by 
Pollard  (Lancet,  May  30,  1885.)  A  woman  of  19 
years  has  gonorrheal  vaginitis  for  36  days.  Autopsy 
shows  pus  in  the  knee  and  hip  joints,  the  articular 
cartilages  are  eroded,  and  there  is  embolism  of  the  left 
common  iliac,  the  internal  iliac  and  the  vayrinal  veins. 


78  THE    SEQUELAE    OF    GONORRHEA 


y. 

Sequale  Peculiar  to  the  Male. 


The   Part   Played    hy    the   Prostate   in    Gonorrheal 

Disease. 

A  BRIEF  review  of  the  topographical,  gross  and 
microscopic  anatomy  of  the  prostate  readily  shows  its 
great  importance  in  septic  conditions  of  the  urethra. 
It  is  a  compound  tubular  gland,  supported  by  a  frame- 
work of  connective  tissue  and  involuntary  muscle  fibre. 
The  glands  are  arranged  radially  around  the  urethra 
and  their  ducts  open  into  the  prostatic  sinuses  on  either 
side  of  the  verumontanum.  They  are  30  to  40  in 
number  and  are  lined  by  a  single  layer  of  columnar 
epithelium.  Inmeshed  in  the  glandular  walls  are  the 
lymj)hatics  which  follow  the  veins  of  the  prostatic 
plexus  and  end  in  the  internal  iliac  Ij^mphatic  nodes. 
The  whole  prostate  is  enveloped  in  a  fibrous  capsule 
which  is  formed  by  a  condensation  of  the  stroma  of 
the  gland  itself  and  is  distinct  from  the  retro-vesical 
layer  of  the  pelvic  fascia.  Between  this  investment 
and  the  pelvic  fascia  is  the  prostatic  plexus  of  veins 
which  lies  on  the  anterior  and  lateral  aspects  of  the 
gland.  This  disposition  of  the  fascia  is  to  be  regarded 
as  the  fortunate  provision  against  the  invasion  of  the 
pelvic  peritoneum  by  septic  organisms  from  urethral 


IN    BOTH    SEXES.  79 

and  prostatic  suppurations.  The  position  of  the  pros- 
tatic plexus  therefore  is  such  as  to  render  it  more 
Hable  to  injury  by  instrumentation  than  if  it  were  pos- 
terior to  the  gland.  The  prostate  is  pierced  by  the 
ejaculatory  ducts  and  the  urethra,  and  it  receives  infec- 
tion from  the  urethra  and  in  turn  communicates  the 
same  to  the  seminal  vesicles. 

Prostatic  involvement  in  gonorrhea  is  very  common 
indeed.  In  400  cases  of  gonorrhea  Colombini  (Giorn- 
Ital.  delle  Mai.  Yen,  1896,  No.  5,)  found  that  33% 
had  involvement  of  the  prostate,  seminal  vesicles 
and  vas  deferens.  Of  these  160  were  acute  cases  of 
which  32  had  prostatitis,  and  15  prostatitis  and  seminal 
vesiculitis ;  180  were  subacute  with  35  complicated  by 
prostatitis  and  4  by  seminal  vesiculitis;  60  were 
chronic  with  21  of  prostatitis  and  3  with  vesiculitis. 
In  190  cases  Poehl  found  the  prostate  involved  in 
39.7%.  Montagnon  and  Eraud  consider  that  70%  of 
all  cases  invade  the  posterior  urethra. 

Prostatic  involvement  does  not  usually  occur  before 
the  third  week  of  infection,  but  may  begin  much 
earUer  if  there  is  instrumentation. 

Patliology. — The  pathology  of  acute  and  chronic 
prostatitis  resembles  that  already  described  as  com- 
mon to  gonorrheal  infection  of  Cowper's,  Bartholini's, 
Skene's  and  other  glands.  There  is  at  first  acute  con- 
gestion which  follows  immediately  on  the  invasion  of 
the  follicles  by  the  bacteria.  The  next  step  is  that  of 
acute  folliculitis  with  infiltration  of  the  epithelium, 
local  leucocytosis,  destruction  of  cells,  desquamation, 
the  formation  of  phlegmonous  nodules  which  may 
resolve   or    continue    on   to    the    formation   of  small 


80  THE  SEQUELAE  OF  GONORRHEA 

abscesses.  The  process  may  be  limited  to  small  radi- 
cles or  continue  by  continuity  of  tissue  and  involve 
the  parenchyma  of  the  organ.  With  this  there  is 
great  destruction  of  tissue,  and  the  formation  of  mul- 
tiple or  single  abscesses,  of  varying  size,  which  may 
rupture  into  the  urethra  or  may  form  channels  in 
the  path  of  the  least  resistance  through  the  fascia 
already  described.  In  102  cases  of  suppurative  prosta- 
titis observed  by  Finger,  64  ruptured  into  the  urethra, 
43  into  the  rectum,  8  into  the  ischio-rectal  fossa,  in 
3  inguinal  abscesses  formed,  in  2  pus  escaped  through 
the  obturator  foramen,  in  1  through  the  umbilicus, 
1  case  through  the  sciatic  foramen,  in  1  it  escaped  at 
the  border  of  the  false  ribs,  in  1  into  the  abdominal 
cavity  and  one  into  the  space  of  Retzius. 

An  important  contribution  to  the  pathology  of  this 
condition  is  made  by  Young  {op.  cit.)  who  found  the 
gonococcus  together  with  the  B.  coli  in  fluid  aspirated 
from  the  bladder  in  a  case  of  abscesses  and  perineal 
fistula  following  stricture.  In  this  case  there  were 
multiple  abscess  cavities  and  sinuses  and  the  tissue 
was  transformed  into  a  spongy  but  firm  mass  not 
easily  torn,  consisting  of  a  fine  fibrous  stroma  from 
the  meshes  of  which  yellowish-brown  pus  could  be 
pressed. 

Coincident  with  suppurative  conditions  of  the  pros- 
tate there  is  frequently  infectious  phlebitis  of  the 
prostatic  plexus,  the  anatomy  of  which  has  already  been 
alluded  to.  The"  usual  features  of  phlebitis  are  ob- 
served on  dissection  and  microscopial  examination. 
The  prostate  is  enlarged,  elastic  and  painful  on  palpa- 
tion, the  vessels  are  indurated  and  cord-like.  Section 
shows  thrombosis  from  the  filling  of  the  lumen  of  the 


IN    BOTH    SEXES.  81 

veins  with  coaguluin  which  soon  becomes  septic,  the 
vessel  wall  may  ulcerate,  rupture  occurs  with  the  out- 
pouring of  septic  materials,  and  localized  abscesses 
form  which  may  burrow  in  the  directions  already 
noted.  Embolism  from  prostatic  thrombo-phlebitis 
readily  occurs  and  general  infection  may  result.  In 
elderly  men  there  is  frequently  a  dilated  condition  of 
the  veins  of  this  plexus,  the  valves  atrophy  and  fail  to 
fill  their  function  thereby  increasing  the  possibilities 
of  embolism. 

Attention  is  called  to  the  representative  photomi- 
crographs of  sections  made  by  the  writer  in  the  study 
of  the  pathology  of  gonorrheal  disease  of  the  prostate, 
representing  the  stages  of  degeneration  from  the  nor- 
mal, to  that  of  total  destruction  of  prostatic  tissue. 

The  Role  of  Gonorrhea  in  the  Etiology  of  Prostatic 
Hy'pertro'phy . 

All  cases  of  prostatic  hypertrophy  may  be  divided 
into  two  classes,  the  first  in  which  the  increase  in  size 
is  due  to  a  tumor  formation  such  as  fibromyoma, 
fibroadenoma  or  adenomyoma;  the  second  in  which 
there  is  general  increase  in  the  size  of  the  organ 
without  tumor  formation  and  with  increase  of  connec- 
tive tissue.  The  most  complete  and  exhaustive  study 
of  this  problem  has  been  made  by  Ciechanowski  (Mit- 
theilungen  aus  den  Grenzgebietender  Med.  u.  Chir. 
Jena,  1900,)  who  concludes  that  prostatic  hypertrophy 
of  the  aged  is  an  inflammatory  disease  and  that  previous 
urethritis  must  be  held  accountable  for  the  majority 
of  cases.  He  considers  that  the  variety  of  the  hyper- 
trophy is  determined  by  the  primary  locus  of  inflam- 


82  THE    SEQUELAE    OF    GONORRHEA 

mation,  and  if  this  be  near  the  periphery  of  the  pros- 
tate a  marked  increase  of  connective  tissue  will  take 
place  resulting  in  the  hard  variety.  If  the  inflamma- 
mation  starts  centrally  around  the  ducts,  the  large,  soft 
prostate  resembling  an  adenoma  is  formed.  These 
studies  were  confirmed  by  Brooks  (Jnl.  Am.  Med. 
Assn.  Sect,  on  Surg.  1901,  420,)  in  the  examination  of 
thirty  prostates.  These  views  are  disputed  by  Keyes 
(Jnl.  Am.  Med.  Assn.  July  16,  1904,  187,)  who,  in  an 
examination  of  433  cases  of  prostatic  hypertrophy 
found  evidences  of  previous  prostatitis  in  but  eighteen. 
In  these  there  were  no  marked  differentiating  features 
and  he  finds  that  continued  prostatitis  tends  to  cause 
atrophy  rather  than  hypertrophy. 

SyTYiptoras  of  Prostatitis.  —  These  vary  from  ab- 
sence of  pain  with  no  systemic  disturbance,  to  chills, 
high  temperature  and  pulse,  nausea  and  vomiting, 
delirium  and  typhoid  state.  There  may  be  intense 
pain  in  the  prostatic  region,  rectal  palpation  may  be 
impossible,  there  may  be  tenesmus,  hematuria,  pyuria 
and  polyuria.  On  account  of  several  cases  of  prosta- 
titis which  have  been  proved  the  cause  of  general 
infection,  it  is  of  great  importance,  in  post-mortem 
examinations,  to  incise  the  prostate  in  parallel  planes, 
that  all  parts  of  its  mass  may  be  inspected. 

Epididymitis  and  Orchitis. 

These  are  among  the  most  frequent  of  all  complica- 
tions in  the  male  and  usually  result  from  the  direct 
extension  of  urethral  and  prostatic  inflammation  by 
continuity  of  mucous  membrane.  Gross,  Engelmann 
and  Brothers  place  the  ratio  as  17%,  20%  and  26% 


IN    BOTU    SEXES.  83 

of  all  cases  of  gonorrheal  urethritis.  In  28,787  cases 
of  gonorrhea  Neisser  found  epididymitis  in  27.1% 
and  other  comphcations  in  17.8%.  In  the  analysis  of 
285,048  cases,  Morrow  (Social  Diseases  and  Marriage, 
155,)  found  epididymitis  in  16.11%. 

Finger  observed  548  cases  of  epididymitis  in  1,844 
of  urethritis,  and  in  3,136  cases  compiled  by  him  1,500 
were  right  sided,  1,425  were  left  and  211  were  double. 

Pathology.  —  Gonococci  enter  the  duct  and  vas  from 
the  urethra  and  invading  the  epithelium  cause  cloudy 
swelling,  desquamation,  infiltration  of  the  walls,  small 
celled  infiltration  of  the  pericanalicular  tissue,  pro- 
liferation of  connective  tissue,  liquefaction  of  inflam- 
matory products  and  suppm-ation.  If  abscess  forms, 
incision  reveals  crumbly  curdy  pus  and  masses  of  yel- 
low shreds  —  the  coils  of  tubules  which  may  be  teased 
out  with  needles.  Such  abscesses  may  be  multiple 
and  coalesce  forming  a  large  sac  with  almost  complete 
destruction  of  the  testicle,  or  they  may  be  limited  by 
the  septa  of  the  tunica  albuginea  to  one  or  several 
lobules.  Gonococci  may  proceed  through  the  epidi- 
dymis and  invade  the  tunica  albuginea  and  vaginalis 
testis  causing  hydrocele  which  is  serious  or  purulent 
according  to  the  extent  of  the  inflammation.  The 
rupture  of  an  abscess  of  a  lobule  into  the  tunica  vagi- 
nalis is  also  a  cause  of  suppurative  hydrocele  and  an 
inflamed  epididymis  may  become  adherent  to  a  pre- 
existing varicocele  and  infect  the  sac  by  transudation. 
The  inflamation  may  be  limited  to  the  vas,  causing  a 
true  cordonitis  in  which  the  spermatic  cord  can  be 
traced  to  the  external  inguinal  ring  externally,  and  by 
the  rectum,  as  a  hard  elastic  cord,  to  the  prostate. 


84  THE    SEQUELAE    OF    GONORRHEA 

The  rupture  of  an  abscess  of  the  vas  or  seminal 
vesicles  into  the  peritoneum  occurs  in  rare  instances 
and  will  be  referred  to  in  the  discussion  of  peritonitis 
of  the  male. 


Gonorrheal  Disease  of  the  Seminal  Vesicles. 

Finger  (Internat.  klin.  Rundschau.  Wien.  Feb.  12, 
1893,)  was  one  of  the  first  to  call  attention  to  this 
complication  of  gonorrhea,  and  later  observers  have 
shown  the  commonness  of  the  infection.  The  fre- 
quency of  prostatic  involvement  in  urethritis  easily 
accounts  for  the  infection  of  the  ejaculatory  ducts  and 
vesicles  by  continuity  of  epithelium.  Again  we  note 
the  similarity  between  the  anatomy  and  pathology  of 
the  male  and  female  tubules  which  might  be  predicted 
from  the  embryology.  In  the  male  the  vesicles  and 
ducts  and  the  head  of  the  epididymis  are  formed  from 
the  canals  and  duct  of  the  Wolffian  body,  while  in  the 
female  the  Fallopian  tube  is  developed  from  the  duct 
of  Miiller,  a  duct  quite  analogous  with  the  Wolffian, 
being  the  efferent  tube  of  a  contiguous  segmental  organ. 
Microscopically,  the  structure  of  the  folds  of  this  tubular 
organ,  and  of  its  inflammations  very  closely  resembles 
that  of  the  Fallopian  tubes.  The  first  stage  of  inflam- 
mation consists  in  congestion  of  the  mucosa  followed 
by  small  celled  infiltration.  This  difference,  however, 
exists  between  this  stage  of  inflammation  of  the  vesicles 
and  the  tubes,  —  the  substance  of  the  folds  of  the  latter 
is  much  moi'e  readily  invaded  than  is  the  stroma  of  the 
prostate  and  the  rugae  of  the  seminal  ducts.  This  is 
probably  due  to  the  compact  non-vascular,  fibrous 
structure  of  the  latter.     The  next  stage  is  that  of  des- 


IN    BOTH    SEXES.  00 

quamation  of  epithelium  which  continues  until  there  is 
left  only  a  framework  such  as  is  illustrated  in  the 
photomicrograph  of  gonorrheal  abscess  of  the  pros- 
tate. The  figure  illustrates  the  first  stage  of  gonor- 
rheal inflammation  of  the  seminal  vesicle,  and  this  sec- 
tion is  selected  for  photography  from  a  large  number 
of  preparations  as  illustrative  of  both  normal  and  in- 
fected rugae.  In  the  upper  part  of  the  field  it  will  be 
observed  that  the  contour  of  the  gland-like  acini  is  dis- 
tinct and  the  epithelium  quite  uniform  in  thickness. 
Towards  the  free  surface,  however,  the  contour  is  not 
sharp  owing  to  disintegration  of  the  epithelium  and 
the  accretion  of  pus.  In  the  lower  portion  of  the  field 
all  semblance  of  normal  structure  is  lost,  —  the  folds 
are  matted  together  and  with  a  hand-glass  the  corpus- 
cular character  of  the  almost  homogenous  mass  can 
be  distinguished.  With  a  later  stage  of  inflammation 
there  is  complete  destruction  of  the  mucosa,  in  places 
it  remains  adherent  to  the  stroma  and  tube  walls,  at 
other  parts  it  is  entirely  wanting  and  nothing  but  a 
few  pus  corpuscles  remain.  As  a  rule  there  is  but 
little  invasion  of  the  surroimding  structures,  the  fibrous 
investment  ser^dng  as  does  the  stroma  and  capsule  of 
the  prostate,  as  an  almost  impenetrable  barrier  to  the 
suppurative  process. 

In  gonorrheal  disease  of  the  seminal  vesicles  we  find 
another  important  cause  of  sterility  in  the  male. 
Normal  and  vigorous  spermatozoa  may  be  formed  in 
the  tubules,  but  when  surrounded  by  the  contents  of  a 
gonorrheal  vesicle,  they  are  soon  attacked  by  bacteria 
and  lose  their  natality  and  structure.  In  the  writer's 
studies,  smears  were  made  of  the  contents  of  the  vesi- 
cles before  fixing  and  mounting  for  section  cutting,  in 


86  THE    SEQUELAE    OF    GONOREHEA 

order  to  observe  the  character  of  the  desquamated 
epitheUum,  and  it  is  not  infrequently  that  the  vestiges 
of  spermatozoa,  detached  flagellae  and  epithehal  cells 
may  be  observed  in  all  stages  of  disintegration,  often 
with  bacteria  and  gonococci  imbedded  in  their  sub- 
stance. 

We  have  described  the  various  stages  of  gonorrheal 
inflammation  of  the  prostate  gland  from  its  invasion  to 
that  of  destruction  of  tissue  with  only  vestiges  of  struc- 
ture, and  have  considered  it  typical  of  gonorrheal  in- 
flammation of  the  tubes  and  ovaries.  The  analogy  is 
applicable  also  to  the  seminal  vesicles  and  their  ducts. 
The  vesicle  becomes  a  septic  sac,  there  is  wholesale 
desquamation  of  epithelium  and  after  resolution  the 
secreting  surface  is  so  reduced  that  there  is  loss  and 
even  absence  of  the  normal  secretion  upon  which  the 
motility  and  the  migration  of  the  spermatozoa  depends. 
The  present  state  of  our  knowledge  does  not  warrant 
any  statement  as  to  the  regeneration  of  this  epithelium 
after  gonorrheal  disease. 

Symptoms.  —  The  symptoms  of  acute  gonorrheal 
seminal  vesiculitis  are  first  those  of  posterior  urethritis. 
There  may  then  be  any  or  all  of  the  following  symptoms: 
pain  in  the  supra-public  regions  of  either  or  both  sides, 
which  radiates  into  the  hypogastrium  or  into  the  testi- 
cles; chills  and  rise  of  temperature;  rectal  examina- 
tion shows  tenderness  and  swelling  of  the  vesicles, 
edema  and  tumefaction  and  infiltration  of  the  perivesic- 
ular  tissue  often  presenting  a  mass  the  size  of  an  Qgg. 
This  mass  may  be  continuous  with  the  prostate  and 
there  may  be  infection  of  the  spermatic  cord.  The 
appearance  of  pus  in  the  urine  is  variable,  and  may 


IN    BOTH    SEXES.  O/ 

occur  at  the  onset  of  the  attack  or  may  not  appear 
until  the  temperature  and  symptoms  begin  to  dechne, 
and  then  shows  up  in  large  quantities. 

Sequale  of  Minor  Importance,  Balanitis,   Cowperitis, 

etc. 

Phimosis,  balanitis  and  posthitis  of  gonorrheal  origin 
may  exist  without  urethritis.  In  a  recent  case  of  this 
nature  treated  by  the  writer,  there  was  presented  the 
seeming  anomaly  of  gonorrhea  with  typical  pus  cor- 
puscles enclosing  cocci,  but  without  urethritis.  There 
was  an  advanced  degree  of  phimosis  and  the  exudate 
proceeded  from  the  modified  integument.  Notwith- 
standing the  facility  with  which  local  applications  may 
be  applied,  these  are  often  cases  of  great  chronicity  on 
account  of  the  mucous  follicles  and  paraurethral  glands 
which  offer  material  for  auto-reinfection.  The  pa- 
thology of  all  these  conditions  is  that  of  inflammation, 
congestion  and  infiltration  of  the  integiunent,  local 
necrosis  with  superficial  desquamation,  leaving  ulcers 
over  which  there  may  be  a  croupous  deposit  of  exfoliated 
epithelium  and  pus  corpuscles  containing  gonococci. 

Periurethral  abscess  has  already  been  alluded  to  and 
is  an  example  of  the  penetrating  power  of  the  coccus, 
so  stoutly  denied  by  Bumm  and  so  ably  demonstrated 
by  Wertheim.  Were  the  process  continuous  with  the 
urethritis,  the  incision  of  such  an  abscess  would  usually 
be  followed  by  urinary  fistula  as  well  as  by  a  purulent 
gonorrheal  discharge  from  the  urethra  through  the 
wound.  Such  a  condition  is  fortunately  rare  and 
results  only  from  too  deep  an  incision  or  from  delay 
in  operating.     The  extent  of  periurethral  abscesses  is 


88         THE  SEQUELAE  OF  GONORRHEA 

markedly  limited  by  the  fortunate  disposition  of  the 
septum  pectiniforme  and  the  trabeculae,  fibrous  barriers 
which  are  practically  immune  from  inflammation. 

Cowjjeritis  usually  appears  in  the  third  or  fourth  week 
after  urethral  infection  and  is  due  to  extension  from 
the  urethra.  It  appears  as  a  small,  hard,  painful  tumor 
in  the  middle  of  the  perineum.  There  is  usually  great 
pain  on  urination  on  account  of  the  comjDressor  urethrae 
muscle  which  encircles  the  gland.  The  gland  often 
suppurates  and  ruptures  into  the  urethra  or  perineum, 
—  when  into  the  former  the  condition  is  long  lasting 
on  account  of  contamination.  The  anatomical  topog- 
raphy of  these  glands  shows  several  reasons  for  these 
conditions.  Situated  under  the  urethra,  their  ducts 
pointing  upwards,  surrounded  by  the  compressor  ure- 
thrae, which  j)revents  physiological  rest  by  its  increased 
action  in  tenesmus,  it  is  easy  to  see  how  readily  they 
may  become  infected,  and  once  infected  there  is  no 
provision  for  drainage  by  gravity;  the  glands  are 
transformed  into  septic  cisterns,  which  fill  up,  overflow 
and  yet  are  not  drained  away.  With  rupture  into  the 
perineum  or  evacuation  by  incision,  gravitational  drain- 
age is  provided,  and  prompt  resolution  usually  takes 
place. 

Gonorrheal  Peritonitis  in  the  Male. 

In  the  male  the  absence  of  channels  of  compara- 
tively free  communication  between  the  peritoneum 
and  the  genitalia  is  to  be  noted.  But,  from  the  brief 
descriptions  already  given  of  the  divers  ways  in  which 
purulent  foci  may  discharge   and  burrow,  it  is  not  to 


IN   BOTH    SEXES.  89 

be  wondered  that  extra  peritoneal  abscesses  occasion- 
ally burst  into  the  peritoneal  cavity  and  cause  localized 
or  general  peritonitis.  Cases  of  gonorrheal  peritonitis 
in  the  male  are  on  record  from  the  internal  rupture  of 
perinephritic  abscesses,  of  mesenteric  lymph  nodes, 
of  prostatic  abscesses,  of  thrombo-phlebitis  of  vesical 
plexus  accumulations. 

The  bacteriology  of  cases  occurring  in  men  has  not 
been  worked  up  as  carefully  as  cases  occurring  in 
women,  and  nearly  all  recorded  cases  are  open  to  the 
objections  which  attend  any  effort  to  trace  infections 
without  more  complete  data.  The  works  of  Fau9on 
(Arch,  gende  Med.  1877,)  and  Zeissl  (Ann.  des  Mai. 
Genito-Urinaires,  July,  1893,)  are,  however,  prophetic 
and  suggest  that  with  modern  bacteriological  methods 
cases  of  this  kind  will  be  much  more  frequently  ob- 
served. 

Schepelern  reports  a  case  of  a  sailor  who  suffered 
for  three  weeks  with  gonorrheal  urethritis  and  after 
eight  days  of  epididj^mitis  was  suddenly  attacked  by 
right-sided  peritonitis  and  died  in  thirty-six  hours. 

Rougon  (Finger,  op.  cit.)  (L'Union  Med.  1876,  651,) 
observed  a  case  in  a  man  of  thirty-five  who  was  mori- 
bund when  brought  to  hospital  for  treatment,  with 
small  thready  pulse,  nausea  and  vomiting  of  bile,  the 
abdomen  painful  and  distended,  right  epididymitis  and 
acute  hydrocele.  At  autopsy  the  abdomen  is  found 
distended  \vith  gas,  the  peritoneum  is  covered  with  a 
croupous  exudate  Avhich  is  thickest  in  the  right  iliac 
fossa,  there  is  300  cc.  of  sero-purulent  fluid  in  the 
pelvis  and  ihac  fossa,  and  100  cc,  of  similar  fluid  in 
the  right  tunicar  vaginalis  testis,  the  serous  membrane 
being   injected    and   bearing    a  croupous   membrane. 


90  THE    SEQUELAE    OF    GONOEEHEA 

The  right  epididymis  is  swollen,'  reddened,  ecchymotic 
and  containing  foci  of  pus.  The  right  spermatic  cord 
is  thickened  and  its  investments  show  inflammatory 
exudation. 

In  the  writer's  opinion  the  case  so  completely  re- 
ported by  McCosh  (Ann.  Surg,  xxi,  140,)  cannot  be 
classed  among  those  of  gonorrheal  origin,  as  there  is 
no  evidence  that  the  patient  had  gonorrhea  or  that 
the  lesions  were  of  this  nature. 

It  does  not  necessarily  follow  that  gonorrheal  peri- 
tonitis always  goes  on  to  suppuration  and  require 
abdominal  section  any  more  than  peritonitis  caused  by 
other  bacteria.  This  is  illustrated  by  a  case  reported 
by  Brewer  (Ann.  Surg,  xxxiii,  600,)  in  which  a  man 
of  twenty  affected  with  gonorrheal  urethritis  is  sud- 
denly taken  with  paroxysmal  pain  in  the  abdomen 
which  soon  becomes  localized  in  the  right  lower  quad- 
rant. The  abdomen  is  enlarged,  hard  and  exquisitely 
tender.  Palpation  shows  enlargement  of  the  lymph 
glands  along  the  right  iliac  vessels  and  by  rectum  the 
prostate  is  found  to  be  enlarged  and  tender  and  from 
it  there  proceed  a  chain  of  nodes  leading  upwards. 
The  treatment  of  the  urethral  and  prostatic  conditions 
is  followed  by  the  disappearance  of  the  abdominal 
symptoms.  Cases  such  as  this  are  of  important  clini- 
cal application  and  suggest  delay  in  operation  until 
phenomena  develop  which  allow  a  more  complete  in- 
terpretation of  the  abdominal  symptoms. 


IN  BOTH  SEXES.  91 


VI. 

Sequelae  Peculiar  to  the  Female. 


Vagijiitis. 

It  has  been  claimed  by  Bumm  that  the  gonococcus 
was  incapable  of  causing  vaginitis,  but  his  views  are 
strenuously  opposed  by  Schwartz  who  has  found  gono- 
cocci  in  the  deepest  layers  of  the  mucosa  and  has 
observed  cases  of  gonorrheal  vaginitis  in  which  the 
uterus,  urethra  and  vestibule  were  entirely  free  from 
disease.  Sanger  finds  that  the  unabraded  vagina  is 
not  likely  to  be  invaded  by  the  gonococcus,  but  ex- 
periments on  the  human  subject  (See,  op.  cit.)  prove 
conclusively  that  it  not  only  may  exist,  but  that  it 
may  persist  and  be  stubborn  in  its  resistance  to  treat- 
ment. The  following  are  those  factors  which  most 
commonly  predispose  to  gonorrheal  vaginitis  :  —  previ- 
ously existing  vaginitis  caused  by  other  organisms, 
irritating  discharges  from  the  endometrium,  mixed 
infection,  traumatism  of  any  kind  but  particularly 
that  incident  to  parturition. 

Without  prompt  and  appropriate  treatment  nearly 
all  cases  of  gonorrheal  vaginitis  pass  into  the  chronic 
state.  In  fourteen  cases  studied  by  Rudsley  (Medizin- 
sko  Obozryenie,  Moskow,  xlii,  934,)  all  were  character- 
ized by  their  tedious  course,  profound  anemia,  urethral 


92  THE  SEQUELAE  OF  GONOERHEA 

involvement  and  eczema  of  tlie  vulva  caused  by  the 
purulent  discharge. 

Pathology. — Edema  and  infiltration  of  the  introitus, 
thickening  and  infiltration  of  the  folds  of  the  mucous 
membrane ;  there  may  be  desquamation  of  epithelium 
with  the  formation  of  deep  red  angry-looking  erosions 
which  bleed  on  the  slightest  touch.  The  gonorrheal 
vaginitis  of  pregnancy  is  occasionally  seen  in  which 
the  mucous  membrane  is  transformed  into  a  granulat- 
ing surface  and  the  folds  covered  with  red  papillary 
granules,  —  the  so-called  vaginitis  granulosa. 

Vaginismus  may  exist  with  vaginitis  or  be  a  sequel 
to  it. 

Atresia  may  follow  gonorrheal  vaginitis,  —  the  writer 
has  observed  one  case,  and  Eberlin  (Zeit.  f.  Geb.  u. 
Gyn.  xl.  Heft  1,)  notes  two  cases  in  which  operation 
was  necessary. 

Gonorrheal  vaginitis  predisposes  to  a  peculiar  fibrous 
degeneration  called  xerosis  vaginae,  in  which  there  is 
thickening  and  rigidity  of  the  thickened  miiccus  mem- 
brane, the  follicles  become  destroyed  and  the  epithelium 
becomes  devitalized  and  whitened,  a  condition  some- 
times called  psoriasis  mucosae. 

Stricture  of  the  Urethra  in  the  male  is  a  very  common 
sequel  of  gonorrheal  urethritis  and  this  subject  has 
been  so  well  covered  in  literature  and  monographs, 
particularly  that  of  Otis,  that  it  need  not  be  discussed  • 
here.  That  stricture  of  the  female  urethra  also  is  of 
comparatively  frequent  occurrence  is  not  so  well  known, 
and  it  is  to  be  noted  that  gonorrhea  is  the  most  com- 
mon cause  of  this  disease  in  young  and  middle  aged 


IN    BOTH    SEXES. 


93 


women.  Herman  (Trans.  London  Obst.  Soc.  1887,  43,) 
publishes  a  table  of  twenty-eight  cases  in  which  seven 
were  of  gonorrheal  origin.  He  describes  others  which 
were  due  to  caustics  employed  in  treatment. 

Inflammation  of  Skene  s  GlancU  is  very  commonly 
if  not  always  of  gonorrheal  origin.  These  glands  lie 
in  the  connective  tissue  of  the  vestibule  and  their 
ducts  enter  the  urethral  floor  just  within  the  meatus. 
In  100  cases  of  gonorrheal  urethritis  Pollak  (Zent.  f. 
Gyn.  1903,  ix,)  found  these  glands  involved  in  45%. 
Of  these  68%  were  of  one  gland  and  the  remainder 
were  bilateral.  His  studies  showed  that  the  ducts  of 
these  glands  frequently  contained  gonococci  long  after 
their  disappearance  from  all  other  parts  of  the  genital 
tract  and  that  in  this  way  they  are  a  frequent  source 
of  auto-reinfection. 

Bartholinitis  is  one  of  the  most  common  external 
manifestations  of  gonorrheal  vaginitis  and  urethritis. 
The  bacteria  invade  the  efferent  duct  which  soon  be- 
comes occluded  by  the  inflammatory  thickening  of  its 
epithelium  and  the  infiltration  of  the  surrounding 
tissues.  The  glandular  tissue  is  next  invaded,  the 
sub-epithelial  layer  is  penetrated,  there  is  globular 
swelling  of  the  gland  from  distension  and  if  the  cyst 
be  not  relieved  by  incision  there  may  be  infiltration  of 
the  surrounding  cellular  tissue.  If  pus  breaks  through 
the  capsule  of  the  gland  without  rupturing  externally, 
extensive  sinuses  may  form  leading  to  the  perineum, 
vagina  or  rectum.  Surgery,  by  early  incision,  usually 
averts  any  such  unnecessary  complication  by  relieving 
tension  and  providing  drainage.     In  a  notable  series 


94         THE  SEQUELAE  OF  GONOKRHEA 

of  studies  Bumm  has  demonstrated  all  stages  of  glan- 
dular inflammation  from  the  initiatory  invasion  of  the 
acini  to  suppuration  and  destruction  of  tissue.  Eeso- 
lution  may  occur  without  suppuration  if  the  infection 
be  of  a  low  grade  of  virulence. 

Gonorrheal  Salpingitis. 

The  mechanical  forces  which  favor  involvement  of 
the  uterus  and  Fallopian  tubes  in  bacterial  disease 
have  already  been  discussed.  Although  the  tubes  are 
plentifully  supplied  with  blood  vessels  and  lymphatics 
it  is  probable  that  the  inoculation  of  the  mucous  mem- 
brane with  particles  from  the  uterine  cavity  is  the  first 
step  in  the  inauguration  of  an  inflammatory  process. 
When  salpingitis  is  once  established,  however,  infection 
may  spread  through  the  lymphatics  and  blood  vessels 
as  has  been  observed  by  the  writer  as  well  as  by 
Krause.     (Monat.  f.  Geb.  u  Gyn.  xvi,  192.) 

Gonorrheal  salpingitis  is  of  greater  frequency  than 
is  usually  supposed,  the  number  of  case^  depending 
directly  uj)on  the  gonococcus  being  much  greater  than 
those  in  which  the  organism  is  found  after  operation 
or  post-mortem,  —  and  for  the  reasons  already  given. 
Andrews  (Am.  J.  Obst.  Feb.  1904,  177,)  in  684  cases 
found  55%  sterile,  the  gonococcus  in  22%,  staphy- 
lococci and  streptococci  in  10%,  the  pneumococcus  in 
2%  and  the  B.  coli  communis  in  2.5%.  Schmitt  (Zeit. 
f.  Geb.  u.  Gyn.  xxi.)  finds  that  gonorrhea  extends  to 
the  uterus  in  20%  and  to  the  tubes  in  5%  of  cases. 
In  11 G  cases  of  purulent  salpingitis  Werthein  found 
72  sterile,  32  showed  the  gonococcus,  6  the  strepto- 
coccus  and  one   the  staphylococcus.     In  43   cases  of 


IN  BOTH  SEXES.  96 

pyosalpiiix  Kelley  found  33  negative,  the  gonococcus 
in  7  and  the  B.  coll  in  none. 

Recent  bacteriological  studies  have  shown  beyond 
cavil  that  the  gonococcus  can  lie  encysted  or  dormant 
in  the  tubal  or  ovarian  tissue  indefinitely,  and  this 
knowledge  renders  all  the  more  complex  the  important 
question  of  the  curability  of  gonorrhea  in  the  female. 
It  is  thus  seen  that  a  tube  which  may  appear  normal 
to  the  eye  may  on  careful  preparation  show  foci  of 
gonococci,  and  it  is  for  this  reason  that  Doderlin  urges 
the  extirpation  of  both  tubes,  if  one  is  known  to  be  in- 
fected, —  a  teaching  which  is  finding  ready  acceptance 
among  progressive  gynecologists. 

Infantile  salpingitis  is  undoubtedly  a  common  dis- 
ease. And  it  is  to  be  believed  that  many  cases  of 
infantile  gonorshea  causing  but  few  pelvic  or  abdominal 
symptoms  in  infancy  and  seemingly  making  good  re- 
coveries at  the  time,  remain  quiescent  until  puberty, 
then  develop  insidiously,  causing  obscure  pelvis  symp- 
toms, salpingitis  with  the  possibility  of  rupture  of  the 
sac  and  peritonitis.  It  must  be  remembered  that  the 
larger  number  of  cases  of  infantile  gonorrhea  occur  in 
crowded  tenement  districts  where  children  are  herded 
together  and  where  the  sick  have  but  little  care  unless 
seriously  ill.  Again,  it  is  well  known  that  it  is  next 
to  impossible  to  impress  upon  the  great  majority  of 
patients  the  importance  of  professional  guidance  and 
treatment  after  the  acute  symptoms  are  over,  and  most 
gonorrheal  patients  consult  a  physician  only  while 
there  is  pain  or  discharge.  In  the  case  of  infants  the 
gonococci  may  remain  in  the  tubal  walls  or  lumen  until 
the  time  of  first  menstruation,  the  tubes  then  become 
congested,   suitable  culture   medium  is  provided  for 


96  THE  SEQUELAE  OF  GONORRHEA 

their  multiplication  and  womanhood  is  burdened  with 
pelvic  disease  from  the  first. 

Bidwell  and  Carpenter  (Br.  J.  Children's  Diseases, 
Oct.  1904,)  report  two  interesting  cases : 

I.  A  girl  of  six  has  purulent  discharge  from  the 
vulva,  superficial  ulceration  of  external  genitals,  hema- 
turia, painful  swelling  of  the  right  foot  with  redness 
and  edema  over  the  flexor  tendons,  temperature  102°  F. 
Incision  evacuates  clear  fluid  from  the  tendon  sheath. 
Two  weeks  there  is  abdominal  swelling  and  on  celi- 
otomy both  tubes  are  found  to  be  full  of  gonorrheal 
pus.  The  vaginal  discharge  persisting  dilatation  of  the 
cervix  with  currettage  of  the  uterus  is  performed  and 
followed  by  prompt  recovery. 

II.  A  girl  of  three  and  one-half  years,  vaginal  dis- 
charge for  six  weeks,  rectal  bimanual  shows  bilateral 
salpingitis.  One  month  later  one  of  the  enlargements 
had  subsided  and  in  another  month  the  pelvis  was 
apparently  free  from  disease. 

Bidwell  suggests  curettage  in  all  cases  of  uterine 
gonorrhea  as  the  most  eflicacious  means  of  preventing 
tubal  involvement.  The  writer  would  oppose  such  a 
procedure  for  the  following  reasons  :  The  possibility 
that  the  tubes  are  already  infected ;  the  fact  that 
gonorrheal  endometritis  is  not  always  cured  by  curret- 
tage ;  the  probability  of  increase  and  extension  of  the 
inflammatory  process  by  the  traumatism  of  operation. 

Pathology.  —  As  might  be  supposed  from  our 
knowledge  of  the  source  of  infection,  the  course  of 
salpingitis  is  from  the  lumen  of  the  tube  into  its  sub- 
stance.    The  epithelium  of  the  villous-like  folds  is  first 


IN  BOTH  SEXES.  97 

attacked,  the  cells  becoming  invaded  by  gonococcis 
which  proceed  into  the  sub-epithelial  structure  and 
cause  local  leucocytosis.  There  is  immediately  an 
outpouring  of  pus  which  does  not  differ  microscopically 
from  that  of  acute  gonorrheal  urethritis  when  taken 
in  the  early  stage  of  tubal  inflammation,  but  showing 
cellular  detritus,  eosinophiles  and  plasma  cells  if  ob- 
served when  the  inflammatory  process  is  well  under 
way.  The  tubal  folds  soon  become  matted  together, 
forming  a  shapeless  mass  with  hardly  a  vestige  of  the 
original  villous  structure,  and  with  the  further  progress 
of  the  process  there  is  complete  destruction  of  the 
membranous  portion  of  the  tube  which  is  converted 
into  putrescent  sack  if  unruptured, — a  necrotic  slough 
if  still  further  advanced  in  the  bacterial  process. 

In  the  photomicrographs  herewith  presented  the 
several  stages  of  gonorrheal  inflammation  are  illus- 
trated. In  the  cases  from  which  these  specimens  were 
taken  the  gonococcus  was  positively  identified  in  the 
tubal  exudate.  It  is  occasionally  possible  to  observe 
the  gonococcus  in  the  tissues,  but  the  picture  does  not 
differ  from  those  so  frequently  seen  in  text  books. 
Brief  descriptions  accompany  each  photomicrograph. 

In  the  examination  of  stained  sections  of  gonorrheal 
tubes  it  does  not  appear  that  the  infiltration  decreases 
uniformly  as  views  are  taken  at  increasing  distances 
from  the  epithelium,  but  rather  that  clearly  defined 
strata  of  pus  cells  appear  in  the  tissue,  the  substance 
around  such  masses  being  but  sparsely  involved.  Nor 
does  it  appear  that  the  infection  proceeds  by  the  blood 
vessels,  as  we  have  seen  it  does  in  gonorrheal  jorosta- 
titis,  so  it  is  to  be  inferred  that  these  strata  represent 
foci  favorable  to  the  development  of  those  gonococci 


98  THE  SEQUELAE  OF  GONORRHEA 

which  have  found  their  way  into  the  tube  substance 
by  way  of  the  lymphatics.  These  foci  lie,  for  the 
most  part,  along  the  perimysium  and  in  advanced 
cases  the  muscular  layer  is  stratified  with  them.  On 
coming  to  the  peritoneal  layer  the  picture  of  intense 
infiltration  with  polymorphonuclear  and  plasma  cells 
is  again  observed.  It  would  seem,  therefore,  that  in 
gonorrheal  salpingitis  the  inflammatory  involvement 
is  found  in  three  zones,  the  membranous  and  peritoneal 
layers  being  the  most  intense  while  the  intermediary 
is  but  partly  affected. 

It  has  hitherto  been  the  opinion  of  investigators 
that  the  invasion  of  the  substance  of  the  villous  folds 
of  the  tubal  mucosa  occurred  after  the  penetration, 
destruction  and  desquamation  of  the  epithelium  by 
the  gonococcus.  The  writer  finds  numerous  sections 
which  would  seem  to  show  that  this  is  not  always  the 
case,  and  that  the  sub-epithelial  connective  tissue 
framework  and  even  the  deeper  tissues  of  the  tube 
may  be  infiltrated,  enormously  thickened  and  even 
disintegrated  before  there  is  any  desquamation  of 
the  columnar  cells.  This  may  be  interpreted  in 
various  ways.  It  may  be  that  the  coccus  penetrates 
without  leaving  any  apparent  path  and  develops  in 
the  connective  tissue  of  the  villous  fold  before  the 
lumen  of  the  tube  becomes  filled  with  pus.  It  may  be 
that  invasion  of  the  tube  substance  is  by  the  lymphat- 
ics or  peritoneum,  instead  of  from  the  tubal  lumen. 
Or  it  may  be  that  cocci  may  enter  at  some  minute . 
epithelial  denudation  and  penetrate  deep  into  the  fold 
by  the  minute  lymphatic  channels  which  may  be 
demonstrated  by  suitable  stains. 

As    a   rule    gonorrheal  salpingitis    pursues  a   slow 


IN    BOTH    SEXES.  99 

chronic  course  with  occasional  exacerbations.  Occa- 
sionally, however,  if  the  infection  be  of  a  particularly 
virulent  generation,  or  if  it  be  mixed,  the  suppurative 
process  is  very  rapid  and  disintegration  of  the  tube 
with  fulminating  peritonitis  takes  place. 

Moskowicz  (Cent.  f.  Gyn.  1899,  34,)  reports  an  un- 
usual case  in  which  tubal  pregnancy  existed  with  a 
gonococus  and  staphylococcus  pyosalpinx. 

Gonorrheal  Ovaritis 

is  usually  secondary  to  uterine  and  tubal  gonorrhea 
and  occurs  with  less  frequency  than  gonorrheal  sal- 
pingitis. Infection  reaches  the  ovary  from  within, — 
by  the  blood  vessels  and  lymphatics,  and  from  without 
from  the  free  peritoneal  space.  The  veins  of  the 
pampiniform  plexus  which  anastomose  freely  with  the 
veins  of  the  vagina  and  uterus  are  more  likely  to 
carry  infection  than  are  the  arteries,  which  proceed 
from  the  aorta.  Infection  from  the  free  peritoneal 
space  occurs  when  there  is  a  localized  peritonitis  in 
the  vicinity  of  the  ovary  caused  by  leakage  from  a 
pus  tube. 

Pathology. — Congestion  of  the  ovary  is  followed  by 
infiltration  of  the  stroma  by  serous  or  sero-fibrinous 
exudate  which  causes  increase  in  its  size.  With  this 
inflammatory  swelling  minute  hemorrhages,  take  place 
both  in  substance  of  the  ovary  and  on  its  surface,  and 
these  may  be  readily  observed  in  sections.  Bacterial 
deposits  soon  follow  and  the  breaking  down  of  such 
foci  causes  abscesses  which  vary  from  microscopic  size 
to  the  involvement  of  the  entire  ovary.     An  ovarian 


100        THE  SEQUELAE  OF  GONORRHEA 

abscess  may  rupture  into  the  peritoneal  space  causing 
localized  or  general  peritonitis,  or  it  may  rupture  into 
the  tube,  to  which  it  has  become  agglutinated  by  inflam- 
matory adhesions  forming  a  tubo-ovarian  abscess. 
Instead  of  causing  abscess  formation,  the  inflammation 
may  progress  very  slowly  and  become  chronic  with 
contraction  of  the  stroma  which  causes  the  compres- 
sion and  disappearance  of  the  ovarian  elements, — the 
cirrhotic  ovary  in  which  there  is  hardly  a  vestige  of 
ovarian  tissue. 

Gonorrheal  Endometritis. 

The  probability  of  uterine  involvement  in  a  case  of 
vaginal  or  urethral  gonorrhea  depends  largely  upon 
the  condition  of  the  cervix  uteri.  Normally  the  canal 
opens  as  a  transverse  slit,  but  one-twelfth  of  an  inch  in 
length  and  it  is  closed  by  the  posterior  vaginal  wall 
against  which  the  cervix  rests.  The  canal  is  small, 
and  if  not  previously  dilated  will  just  admit  a  sound 
of  F  5  calibre.  In  multiparae,  however,  lacerations  of 
the  cervix  are  very  frequently  observed  and  the  canal 
is  often  large  enough  to  admit  the  finger  tip,  and  is 
practically  a  continuation  of  the  uterine  cavity. 

Occasionally  fibrosis  of  the  cervix  or  lower  uterine 
segments  imparts  a  rigidity  to  the  cervical  canal  main- 
taining it  as  an  open  tube.  It  is  in  conditions  such  as 
these  that  gonorrheal  endometritis  is  most  commonly 
acquired  and  often  without  either  vaginal  or  urethral 
infection.  All  such  cases  observed  by  the  writer  have 
been  in  multiparae  with  large  open  cervical  canals 
readily  admitting  the  little  finger,  a  calibre  of  about 


IN    BOTH    SEXES.  101 

Symptoms. — Tenderness  of  the  uterus  on  bimanual 
which  may  be  rectal  or  vaginal ;  agonizing  uterine  colic 
if  there  is  cervical  stenosis  or  extreme  flexion ;  a 
uterine  discharge  which  is  at  first  bloody  or  sero-puru- 
lent  and  contains  gonococci  and  which  later  becomes 
viscid  and  gelatinous  containing  few  or  no  bacteria. 
These  acute  symptoms  may  be  intense,  the  suffering 
great,  the  pulse  and  temperature  high,  or  they  may  be 
so  very  slight  as  to  cause  but  little  physical  discomfort. 
The  acute  stage  passes  off  in  from  one  to  three  weeks, 
and,  in  the  subsequent  period  in  which  gonococci  ap- 
pear but  occasionally  in  the  discharge,  it  may  be  im- 
possible to  determine  the  gonorrheal  nature  of  the 
disease. 

Pathology. — The  endometritis  excited  by  the  gono- 
coccus  does  not  differ  in  its  characteristics  from 
catarrhal  inflammations  of  other  epithelial  surfaces. 
Infiltration  of  the  several  layers,  destruction  and  des- 
quamation of  the  epithelium  and  the  covering  of  the 
inflamed  surface  with  pus  all  take  place.  This  may 
subside  without  deep  involvement  of  the  uterine  tissue 
particularly  if  the  organ  is  in  its  normal  position,  in 
which  its  cavity  has  the  advantage  of  gravitational 
drainage,  and  the  cervix  is  large  and  dilated.  Very 
frequently,  however,  enhanced  by  those  forces  which 
favor  gonorrheal  conditions  elsewhere,  the  glandular 
and  deeper  tissues  are  invaded  and  the  condition  be- 
comes one  of  acute  metritis,  —  a  disease  which  is  prone 
to  pass  into  the  chronic  state.  With  this  there  is 
copious  desquamation  of  epithelium  and  proliferation 
of  connective  tissue  which  may  constrict  the  glandular 
and  vascular  elements  causing  villous  excrescences  of 


102        THE  SEQUELAE  OF  GONOERHEA 

great  vascularity.  With  an  advanced  degree  of  inflam- 
mation there  is  almost  complete  destruction  of  the 
endometrium  and  the  periglandular  tissue  becomes  so 
infiltrated  that  its  structure  is  completely  obscured. 
With  the  deep  involvement  of  the  uterine  tissue  comes 
the  invasion  of  the  blood  and  lymph  vessels,  in  which 
the  uterus  is  particularly  rich.  In  this  case  the  uterus 
may  serve  as  a  nidus  for  the  general  distribution  of 
the  infection,  —  either  by  minute  bacterial  particles 
absorbed  as  such  into  the  circulation,  or  by  gonorrheal 
thrombo-phlebitis  similar  in  its  features  to  that  de- 
scribed in  the  discussion  of  the  gonorrheal  involvement 
of  the  prostatic  plexus.  The  enormously  increased 
vascularity  of  the  uterine  mucosa  in  pregnancy  and 
the  puerperium,  together  with  the  increase  in  blood 
pressure  and  in  the  fibrin  forming  content  of  the 
blood  at  that  time,  particularly  predispose  to  this 
pathological  sequence.  It  is  after  gonorrheal  endom- 
etritis that  the  uterine  glands  frequently  undergo 
cystic  degeneration  with  the  formation  of  ovula 
Nabothi,  appearing  as  minute  vesicles  in  the  mucous 
membrane. 

Pelvic  Abscess  is  very  commonly  of  gonorrheal 
origin  and  originates  most  commonly  as  a  complica- 
tion of  perimetritis  after  labor  or  abortion.  In  twenty- 
five  cases  of  pelvic  abscess  Kelley  found  the  gono- 
coccus  in  four,  the  streptococcus  in  three,  the  colon 
bacillus  in  four,  and  twelve  were  sterile.  This  disease 
is  so  completely  discussed  in  literature  that  no  special 
mention  is  needed  here. 


IX  BOTH  SEXES.  103 

Gonorrhea  Complicating  Pregnancy. 

Gonorrheal  endometritis,  as  a  cause  of  sterility  in 
the  female  has  already  been  discussed  as  have  also  the 
anatomical  obstacles  to  the  upward  progress  of  bacteria 
from  the  vagina  during  pregnancy.  The  inception  of 
gonorrhea  during  pregnancy  presents  an  interesting 
problem  upon  which  there  are  but  few  data.  In  101 
cases  of  gonorrhea  which  became  pregnant  Fruehinsholz 
(Cent.  f.  Gyn.  1903,  45,)  found  that  71  went  to  term, 
23  aborted,  and  7  had  premature  labor.  Williams  be- 
lieves that  73%  of  all  abortions  are  due  to  endometritis 
of  gonorrheal  origin,  a  percentage  which  seems  unusu- 
ally high.  Noeggerath  observed  19  abortions  in  53 
pregiiancies  acquired  during  the  course  of  gonorrhea. 

Fruehinsholz  believes  that  acute  gonorrheal  urethri- 
tis does  not  prevent  conception;  26%  of  the  pregnant 
women  in  the  Leipzig  clinic  were  gonorrheal.  0]3pen- 
heimer  found  that  27%  of  the  pregnant  women  at  the 
gynecological  clinic  at  Heidelberg  had  the  disease  and 
40%  of  the  children  born  at  that  institution  had  gonor- 
rheal ophthalmia.  From  these  figures  it  is  readily 
seen  that  the  inception  of  gonorrhea  during  pregnancy 
renders  a  large  nmnber  of  complications  possible. 
That  they  do  not  occur  more  frequently  is  due  to  the 
fact  that  the  fetal  mass  and  the  mucous  plug  in  the 
cervix  of  the  gravid  uterus  are  effectual  obstacles  to 
the  upward  progress  of  bacteria.  The  rupture  of  the 
sac  invites  the  entrance  of  vaginal  organisms  which 
immediately  invade  the  uterine  cavity  and  cause  puer- 
peral infection.  With  advancing  pregnancy  there  is 
the  possibility  that  latent  or  encysted  gonorrheal  par- 
ticles might  be  disturbed  and  cause  febrile  disturbances. 


104        THE  SEQUELAE  OF  GONOKRHEA 

Complicating  the  Puerperium. 

The  puerperium  offers  distinctly  favorable  condi- 
tions for  the  various  genito-urinary  complications  of 
gonorrheal  urethritis.  The  traumatic  and  etiological 
elements  which  combine  to  further  the  infection  have 
been  enumerated  in  the  discussion  of  Mechanics  of 
Gonorrheal  Infection.  With  the  prediction  that  in 
the  future  it  will  be  found  that  the  gonococcus  is  con- 
cerned in  a  very  large  percentage  of  cases  of  puerperal 
infection,  the  attention  is  invited  to  very  brief  abstracts 
of  cases  and  investigations. 

Bumm  {op.  cit.)  found  large  quantities  of  gonococci 
of  large  size  in  the  lochia,  two  to  five  days  after  labor, 
and  concludes  that  the  conditions  are  particularly 
favorable  for  their  development  after  labor. 

Kronig  (Cent.  f.  Gyn.  1893,  No.  8,  157,)  confirmed 
nine  gonorrheal  puerperal  cases  by  culture  on  Wer- 
theim's  medium.  His  findings  as  regards  temperature 
are  characteristic  of  gonorrheal  infections,  one  case 
running  a  normal  temperature  throughout  convales- 
cence which  was  not  protracted,  the  rest  varying  from 
normal  to  40.2°  C.  Of  these  cases  two  only  had  com- 
plication, —  one  a  left-sided  pelvic  peritonitis  with 
exudate,  the    other  parametritis  and  tendo-vaginitis. 

Sanger  reports  a  case  who  acquired  gonorrhea  nine 
days  after  labor  which  speedily  caused  pelvic  peritoni- 
tis which  lasted  for  twenty-two  weeks.  Also  one  in  a 
woman  who  developed  parametritic  infiltration  the 
the  third  week  after  delivery  of  her  sixth  child,  the 
infection  being  admitted  by  a  laceration  of  the  cervix. 

Cumston  reports  several  interesting  cases.  i.  A 
woman  of  twenty-four  years;  5  days  after  labor  the 


IN  BOTH  SEXES.  105 

the  temperature  rose  to  39°  C,  pain  in  the  left  side 
and  sacrum,  the  development  of  an  abdominal  mass 
which  disappeared  in  three  weeks.  Positive  culture 
from  uterus  and  cervix.  ii.  Patient  thirty-five  years, 
chills  following  labor,  pain  and  swelling  in  calf  of 
right  leg  followed  by  pains  in  left  leg.  Development 
of  mass  in  the  abdomen,  posterior  vaginal  colpotomy 
releases  500  cc.  of  greenish  pus.  Convalescence  very 
tedious.  Gonorrheal  ophthalmia  of  child  cut  short  by 
suitable  silver  treatment.  iii.  Patient  thirty  years  of 
age,  four  weeks  after  labor  pain  in  the  right  knee  is 
followed  by  infiltration  and  fluctuation  of  the  joint. 
Thickening  of  the  parametrium,  gonococci  in  cervical 
and  uterine  cavities.  iv.  Woman  of  twenty-seven 
years,  two  weeks  after  labor  gonorrheal  endometritis, 
salpingitis  and  vaginitis,  the  entire  vaginal  mucous 
membrane  being  covered  with  a  greenish-yellow 
exudate. 

A  case  of  unusual  interest  and  significance  is  re- 
ported by  Ashmead  (Am.  Med.  Jn.  Jl.  20,  1901,  92,) 
of  a  woman  who  acquired  gonorrhea  when  four  months 
pregnant.  The  child  was  delivered  at  term  and  was 
found  to  have  healed  opacities  of  both  corneas.  These 
were  treated  by  iridectomy  when  the  child  was  two 
years  old. 

A  case  of  the  writer's  :  A  woman  of  thirty-three 
has  a  miscarriage  at  the  sixth  week.  With  a  positive 
knowledge  of  gonorrheal  urethritis  in  the  husband, 
with  the  development  of  abscesses  of  the  fingers  and 
ankles  of  a  three-year  old  child  which  contained  the 
gonococcus  in  pure  culture,  and  the  positive  history 
of  gonorrheal  vaginitis  and  urethritis  in  the  patient 
herself,  —  it   seems    reasonable    to    presume  that  the 


106  THE    SEQUELAE    OF    GONORRHEA 

abortion  was  caused  by  gonorrheal  endometritis  and 
that  the  endocarditis  which  occurred  in  the  second 
week  of  the  mikl  puerperal  fever  which  followed  was 
due,  indirectly  at  least,  to  the  same  organism. 

Gonorrheal  Peritonitis  in  the  Female. 

In  discussing  the  mechanics  of  gonorrheal  infection 
it  has  been  made  clear  that  women  are  much  more 
liable  to  peritoneal  complications  than  men.  Infec- 
tious particles  find  their  way  to  the  peritoneum  in  the 
following  ways,  —  directly  through  the  lumen  of  the 
tubes;  from  rupture  or  distention  of  pus  tubes;  from 
mechanical  perforation  of  gonorrheal  uterus  or  tubes ; 
from  the  bursting  of  extra-peritoneal  abscesses  wher- 
ever they  may  be,  and  from  thrombo-phlebitis  of 
sub-peritoneal  vessels.  Of  all  of  these  approaches  the 
first  and  second  are  by  far  the  most  usual.  Over-dis- 
tention  of  gonorrheal  tubes  causes  leakage,  causing 
oft-repeated  attacks  of  peritonitis  which  is  localized  if 
the  amount  exuded  be  small,  and  general  if  it  be  large. 
These  attacks  come  on  after  prolonged  or  severe 
physical  exertion,  with  extreme  constipation,  after 
accidental  injuries  whereby  the  abdominal  and  pelvic 
viscera  are  shaken,  and  at  the  menstrual  period  when 
pelvic  congestion  is  the  greatest.  The  later  months 
of  pregnancy  bring  increased  tension  on  a  distended 
pus  tube  and  the  violent  muscular  contractions  of  par- 
turition may  cause  increased  pressure  on  the  tubes. 

The  mechanical  abrasion  or  perforation  of  the  uterus 
by  instruments  or  curette  may  be  the  cause  of 
gonorrheal  peritonitis,  and  operations  for  the  relief  of 
gonorrheal  foci  in  the  pelvis  may  assist  the  entrance  of 


IN    BOTH    SEXES.  107 

the  cocci  to  the  peritoneal  cavity  as  has  been  shown  by 
two  cases  of  Kossman.  (Munch,  med.  Woch.  Nos.  10 
and  12.)  The  bursting  of  a  sub-peritoneal  abscess  is  a 
rare  occurrence  and  may  come  from  an  abscessed 
lymph  node  under  the  abdominal  or  pelvic  peritoneum, 
from  a  gonorrheal  abscess  of  the  kidney  or  from  intra- 
mural enc^^stment  such  as  has  been  described  hy  Ceppi. 
(Gaz.  hebd.  de  Sci.  Med.  Montpelier,  May  29,  1901.) 

The  important  features  of  gonorrheal  peritonitis  are 
illustrated  by  the  following  brief  case  reports : 

Kelley.  (Med.  News,  Oct.  19,  1895,  432.)  Two 
cases  of  gonorrheal  peritonitis  from  recent  tubal  rup- 
ture. Intestines  agglutinated  in  all  directions,  — much 
free  pus.  Great  prostration  and  rapid  pulse.  The 
effects  on  the  system  in  gonorrheal  peritonitis  are  by 
no  means  as  great  as  those  caused  by  streptococcus 
and  staphylococcus  infections.  He  considers  these 
cases  particularly  favorable,  the  organism  one  of  very 
low  vitality,  and  does  not  drain  them. 

Richardson.  (Ibid.)  A  case  of  septic  fulminating 
gonorrheal  peritonitis,  a  mass  of  swollen  lymph  glands 
just  above  Poupart's  ligament  containing  gonorrheal 
pus  furnishing  the  infecting  focus.  Operation  did  the 
patient  no  good,  death  resulting  from  general  peri- 
tonitis. 

Frank  &  Koehler.  (Am.  J.  Obst.  xlv,  3.)  i.  Woman 
of  seventeen,  uterine  gonorrhea  from  contaminated 
vaginal  sponge,  —  chills,  headache,  rapid  development 
of  pyosalpinx.  Operation  shows  pus  in  the  left  broad 
ligament;  abdominal  irrigation,  drainage  tube,  ab- 
dominal wall  sewn  around  it.  Septic  peritonitis  de- 
velops in  twenty-four  hours  with  vomiting,  delirium 
and  death  in  seventy-two  hours  after  the  operation. 


108        THE  SEQUELAE  OF  GONOERHEA 

Post-mortem,  one  pint  of  pus  found  in  the  pelvis, 
entire  peritonemn  inflamed,  intestinal  peritoneum 
swollen,  soft  and  ecchymosed,  intestines  agglutinated, 
free  pus  here  and  there  in  the  peritoneal  cavity  among 
the  intestinal  coils.  Pure  culture  of  gonococci  on 
blood  serum,  no  other  organisms. 

ii.  Woman  of  thirty-seven,  colored,  presenting 
symptoms  of  intestinal  obstruction,  is  in  a  state  of 
collapse,  drugs  and  enemata  fail  to  move  bowels. 
Hard  round  mass  on  left  side  of  abdomen  resembling  a 
fibroid  tumor.  No  operation  on  account  of  poor  con- 
dition of  patient.  One  stool  after  eight  minims  of 
Croton  oil  with  but  slight  improvement  in  patient's 
condition,  the  nausea  and  vomiting  continues.  Six 
days  later  pain  appears  in  the  left  leg,  there  is  anes- 
thesia to  the  knee,  foot  is  cold  and  a  needle  driven 
deeply  into  the  leg  cannot  be  felt,  the  Umb  becomes 
dry,  discolored  and  fourteen  days  after  the  beginning 
of  the  attack  is  gangrenous.  At  this  time  the  left 
parotid  gland  begins  to  swell,  at  first  as  a  small  nodule 
later  increasing  in  size  and  fluctuating.  Death  three 
days  later,  nausea  and  vomiting  persisting  until  the 
end.  Post-mortem :  Diffuse  peritonitis,  intense  con- 
gestion of  the  intestines,  free  pus  in  the  cavity.  A 
large  mass  of  thick  jelly  like  purulent  material  sur- 
rounding the  caput  coli,  filling  the  entire  iliac  region 
and  proceeding  from  a  large  abscess  of  the  right  Fal- 
lopian tube.  Uterus  is  studded  with  fibroids,  some  of 
them  calcified  and  others  edematous  and  suppurating. 
The  tumor  on  the  left  side  observed  before  operation 
and  thought  to  be  a  fibroid,  proves  to  be  a  tubal  abscess 
containing  a  pint  of  pus.  At  the  bifurcation  of  the 
left  femoral  vein  is  a  large  adherent  clot  completely 


IN    BOTH    SEXES.  109 

blocking  the  trunk  as  well  as  both  branches,  the  ves- 
sels at  this  point  showing  the  usual  changes  of  endo- 
phlebitis.  The  parotid  contains  ten  ounces  of  pus. 
Gonococci  are  found  in  the  gangrenous  tissues,  the 
femorals,  the  parotid  gland,  the  uterus  and  both 
tubes. 

A  case  reported  by  Young  (op.  cit.)  presents  several 
important  features.  A  girl  of  eighteen,  with  urethri- 
tis, vaginitis,  salpingitis  and  general  peritonitis,  —  all 
of  gonorrheal  origin.  The  low  temperature  of  gonor- 
rheal infections  has  already  been  noted  and  in  this 
case  the  temperature  was  98.6°  F.  and  the  pulse  100 
and  of  good  quality.  Respirations  34,  and  a  leuco- 
cytosis  of  26,000.  Operation  shows  the  peritoneum 
greatly  injected  and  uniformly  covered  with  a  layer  of 
fibrin.  The  under  surface  of  the  liver,  the  spleen, 
stomach  and  pelvic  viscera  are  deeply  injected  and 
thickly  covered  with  exudate.  Tubes  and  appendix 
covered  with  lymph  and  on  pressure  a  drop  of  pus  is 
seen  at  the  tubal  aperture.  Both  tubes  removed,  vis- 
cera sponged  and  lymph  removed  wherever  possible, 
small  drain  leading  to  the  pelvis  is  left  in.  Unevent- 
ful recovery.  Cultures  from  fibrinous  exudate  from 
Douglas's  pouch  and  under  surface  of  liver  show  gono- 
cocci. 

This  case  closely  resembled  perforative  appendicitis 
but  had  the  low  pulse  and  temperature  of  a  subacute 
process.  It  might  be  argued  from  this  clinical  history 
in  which  there  is  such  extensive  involvement  of  the 
abdominal  and  pelvic  peritoneum,  that  the  gonococcus 
was  short  lived  and  its  toxin  feeble,  —  a  teaching  in- 
sisted on  by  many  of  the  earlier  writers.  The  writer 
has  been  unable  to  find  record  of  any  abdominal  case 


110         THE  SEQUELAE  OF  GONORRHEA 

with  such  extensive  inflammation  of  the  peritoneum 
due  to  other  pyogenic  organisms  which  has  survived, 
and  it  would  be  expected  that  j^rofound  toxemia  would 
result  from  so  large  an  infected  surface. 

In  a  case  reported  by  Penrose  (Med.  News,  July  5, 
1890,  Ivii,  16,)  a  man  suffering  from  a  particularly  viru- 
lent gonorrheal  urethritis  infects  his  wife,  who  had 
been  delivered  of  a  healthy  child  one  month  before. 
Two  days  after  the  infection  there  is  dysuria,  swelling 
and  pain  in  the  vulva ;  three  days  later  there  is  severe 
pelvic  pain  especially  on  the  right  side,  free  bleeding 
from  the  vagina,  diarrhea  and  abdominal  disteiition 
with  great  pain.  Abdominal  section  shows  the  parietal 
peritoneum  one-eighth  inch  thick,  dark  red  and  gran- 
ular in  appearance  and  bleeding  easily ;  distention  of 
all  visible  intestinal  loops  which  show  the  same  red 
granulations  which  bleed  on  the  slightest  pressure  of 
sponges.  Tubes  the  size  of  index  finger,  rigid,  en- 
gorged and  the  fimbriae  turgid,  containing  puriform 
fluid  and  thickened  throughout  by  young  celled  de- 
posit. Cocci  but  not  gonococci  are  found  in  the  fluid. 
In  this  case  the  recent  gonorrheal  infection  and  the 
red,  easily  bleeding  granulations  are  strongly  suggest- 
ive of  the  gonorrheal  nature  of  the  case,  but  the  fail- 
ure to  find  the  organism  in  a  case  of  such  acute  onset 
and  such  short  duration  might  seem  a  cogent  argu- 
ment to  the  contrary,  unless  one  shares  in  the  view 
offered  by  some  students  of  this  problem,  that  gono- 
toxin  alone  is  capable  of  producing  intense  reactions 
in  suscej)tible  individuals  without  the  presence  of  the 
parent  organism. 

The  following  are  references  to  cases  of  gonorrheal 
peritonitis  of  other  observers  : 


IN    BOTH    SEXES.  Ill 

Challan.  (Gaz.  di  Torini,  1893,  xi,  792.)  Uncom- 
plicated urethral  gonorrhea  followed  in  eight  days  by 
suppurative  peritonitis  in  which  the  gonococcus  was 
the  only  organism  found. 

Mermet.     (Ann.  des  Org.  Gen.-Urin.  1893,  965.) 

Gushing.  (Jhu.  Hop.  Hospt.  Bull,  xiii,  247.)  Twelve 
cases  in  which  the  peritonitis  is  dry  or  fibrous  with  but 
little  pus  or  exudate. 

Northup.  (Arch.  Ped.  1903,  910.)  Two  cases  in 
girls. 

Comby.  (Arch,  de  Med.  des  Enfants,  Vol.  xiii.) 
Eight  cases  in  girls  of  thirteen  years  and  under. 

Huber.  (Bost.  Med.  &  Surg.  J.  cxxi,  1899,  413.) 
A  case  suggestive  of  gonorrheal  peritonitis  but  not 
positively  proven  such. 

Hunner.  (Jhn.  Hop.  Hospt.  Bull.  Oct.  1902,  xiii, 
247.)  An  interesting  series  of  thirty-two  cases.  Seven- 
teen operated  on  with  thirteen  recoveries.  Of  those 
not  operated  on  eight  recovered  and  six  died,  but  all 
of  these  were  moribund  when  presented  for  treatment. 
Characterizing  these  cases  is  the  peculiar  fact  that 
they  may  be  very  sick  at  first  but  suddenly  take  a 
turn  for  the  better.  Their  resemblance  to  appendi- 
citis is  very  marked,  but  in  this  observer's  opinion  if  it 
is  possible  to  make  a  positive  diagnosis  of  gonorrheal 
infection  it  is  better  not  to  operate  but  to  wait  for  the 
favorable  turn,  in  the  natural  course  of  the  infection. 

Additional  bibliography : 

Chaput.     Peritonite  Blenorrhagique,  Bull,  cle  la  Soc.  Anat.  de 

Paris,  1904,  9,  246. 
Brose.     Ueber  der  diffuse  gonor.   Periton.   Berl.   klia.  Woch. 

xxxiii,  779. 


112         THE  SEQUELAE  OF  GONOREHEA 

V.  Leyden.     Diffuse  eiterig-fibrinose  Periton.  mit  Gonok.  befnnd. 

Mittheilung,  Verein  f.  inn.  Med.  27,  xi,  1899. 
DoDEBLEiN.    Allgemeine  Periton.  Viet's  Handbuch.  iii,  2,  p.  840. 
MuscATELLo.     La  Peritonite  gon.  dif.  II  Policlinico,  Aug.  1901. 
Von  Brunn.     Cent.  f.  allgeni.  Path.  u.  path,  Anat.  xii,  No.  1. 

Gonorrhea  as  a  Cause  of  Sterility  in  the  Female. 

Conception  depends  upon  the  proper  development, 
migration  and  arrest  of  the  male  and  female  gametes. 
The  obstacles  to  the  development  of  the  microgamete 
have  been  desci'ibed  in  the  pathology  of  orchitis,  the 
proliferating  epithelium  of  sperm  cells  being  choked 
by  connective  tissue  or  destroyed  by  suppuration. 
In  the  female  sterihty  may  be  due  to  the  imperfect 
development  of  the  ovule,  obstruction  to  its  progress 
to  the  uterus,  or  unsuitable  environment  in  the  uterus 
should  the  fertilized  ovum  reach  the  endometrium. 
Gonorrhea  is  capable  of  causing  all  of  these  states. 
Gonorrheal  disease  of  the  ovary  destroys  germinating 
protoplasm,  peri-ovaritis  or  peri-salpingitis  prevents  an 
ovum  from  reaching  the  fimbriated  ends  of  the  tubes. 
But  should  an  ovum  become  matured,  it  cannot  pass 
through  a  Fallopian  tube  destitute  of  epithelium,  per- 
haps filled  with  pus,  agglutinated  by  inflammatory 
connective  tissue  or  distorted  by  peritoneal  adhesions. 
But  should  a  matured  or  fertilized  ovum  reach  the 
uterine  cavity,  there  to  find  a  condition  of  gonorrhea] 
endometritis,  the  environment  is  manifestly  unsuited 
to  its  development  or  life,  it  is  speedily  invaded  by 
various  organisms,  for  the  infection  in  the  uterus  is 
nearly  always  mixed,  and  pregnancy  ceases  almost  as 
soon  as  it  is  begun.  Pregnancy  is  quite  possible  with 
gonorrheal  disease  of  the  urethra,  vagina,  and  possibly 


IN    BOTH    SEXES.  113 

of  the  tubes  and  ovaries,  if  the  process  does  not  inhibit 
the  functions  necessary  to  the  condition,  but  impossible 
if  there  is  endometritis  from  gonorrhea. 

The  important  question  of  operations  on  cases  of 
gonorrheal  affections  of  the  abdominal  and  pelvic 
viscera  is  quite  germain  to  the  subject  matter  of  this 
essay.  Latent  and  subacute  gonorrhea  produce  gener- 
ations which  are  not  only  viable,  but  are  occasionally 
virulent  and  capable  of  producing  a  toxin  which  is 
quite  unparalleled  by  any  produced  in  vitro.  And 
since  it  has  been  known  that  gonorrheal  pus  from  the 
tubes  is  quite  capable  of  producing  fulminating  peri- 
tonitis, gynecologists  are  operating  with  great  caution 
in  cases  of  gonorrheal  infection  of  the  pelvis.  Kronig 
[op.  cit.)  lays  great  stress  upon  this  point  and  urges 
the  probability  of  operative  interference  making  bad 
matters  worse  in  such  cases.  In  the  writer's  opinion 
the  point  of  the  greatest  importance  in  this  question  is 
the  period  of  time  which  has  elapsed  since  the  onset 
of  tubal  symptoms.  The  greater  the  lapse,  the  more 
likely  are  the  contents  to  be  sterile,  a  thing  which  is 
true  of  all  suppurative  processes,  but  particularly  of 
gonorrheal.  In  the  case  of  pus  tubes,  operation  should 
be  deferred  until  the  subsidence  of  all  acute  symptoms 
and  the  cases  of  speedy  death  reported  by  Hunner, 
Kronig,  Koehler  and  others  must  be  taken  as  testimony 
of  great  weight  in  deciding  this  question.  In  the 
event  of  general  or  localized  peritonitis  which  offer 
the  physical  signs  of  pus  accumulations,  the  best  surgi- 
cal thought  still  demands  that  an  operation  be  made 
to  liberate  septic  material. 

As  a  cause  of  death  in  pelvic  and  abdominal  affec- 
tions it  must  be  again  admitted  that  the  streptococcus 


114 


THE  SEQUELAE  OF  GONORRHEA 


surpasses  the  gonococcus  in  activity.  Robb  (Am.  Gyn. 
Trans.  1904,)  shows  this  fact  by  starthng  figures.  He 
reviews  742  cases  of  abdominal  section  in  which  there 
was  a  mortahty  of  3.45%.  Of  these  nineteen  were 
proven  streptococcic  of  which  seven  died,  a  mortality 
of  36.8%. 

The  question  of  the  advisability  of  operations  on 
cases  of  gonorrheal  infection  and  the  comparisons 
already  made  with  the  deportment  of  the  streptococ- 
cus pyogenes  make  it  necessary  to  assemble  those 
points  of  differential  diagnosis  which  are  warranted  by 
the  present  state  of  our  recently  acquired  knowledge 
of  pelvic  inflammations. 


Streptococcus. 
History.    No  venereal  disease. 


Temperature.   High  with  wide 

excursions. 
Pulse.      Corresponding    with 

the  high  temperature. 
Leucocytosis.    High,  to  35,000. 
Pyosalpinx.     Not  common. 
Adhesions.     Many  and  firm. 
Palpation.    Boardy  dense  feel. 
Lesions.     Asymmetrical. 
Vaginal  discharge.     Scanty. 


Gonococcus. 

Of  urethritis,  vaginitis  or  vul- 
vitis with  pus  from  the 
vulva. 

Usually  under  101°  F.  and  of 
low  range. 

Often  under  100. 

Low.     13,000  or  under. 

Usual. 

Not  prone  to  adhesions. 

Boggy  and  spongy. 

Bilateral. 

Profuse. 


IN    BOTH    SEXES.  115 


VII. 

Conclusions. 


Gonorrhea  Predisposing  to  Genito-Urinage   Tubercu- 
losis. 

The  important  question  of  gonorrhea  as  a  possible 
element  in  the  etiology  of  tuberculosis  and  malignant 
tumors  of  the  genito-urinary  organs  is  suggested  by 
the  well-known  fact  that  these  diseases  are  frequently 
engrafted  upon  damaged  tissues.  An  inflamed  respira- 
tory or  intestinal  tract,  crushed  periosteum,  broken 
bone,  previously  inflamed  glands,  —  these  are  the  con- 
ditions which  tuberculosis  finds  most  favorable  for  its 
development.  Now  we  have  in  gonorrhea  and  its 
complications,  together  with  the  operations  and  instru- 
mentation which  seem  necessary  in  its  treatment,  the 
most  common  causes  of  lesions  of  the  genito-urinary 
tracts  of  both  sexes. 

Genito-urinary  tuberculosis,  however,  is  not  a  com- 
mon affection.  In  1,000  autopsies  recorded  by  Osier, 
the  kidneys  were  tubercular  in  but  thirty-two  and  the 
generative  organs  in  but  eight.  In  8,873  surgical 
cases  in  the  Wurtzburg  clinic,  1,287  were  tuberculous, 
but  of  these  only  twenty  were  of  the  genito-urinary 
organs.  In  2,500  autopsies,  on  women  in  the  Dres- 
dener  Krankenhaus,  vesical  tuberculosis  was  observed 
but  four  times. 


116  THE    SEQUELAE    OF    GONORRHEA 

Bearing  in  mind  the  very  great  frequency  of  gonor- 
rhea it  must  be  concluded  that  gonorrheal  urethritis 
does  not  predispose  to  tuberculosis  to  any  extent. 
Occasionally  a  case  is  observed  in  which  gonorrheal 
urethritis  precipitates  a  tuberculous  orchitis  early  in 
its  course.  Such  a  combination  is  usually  character- 
ized by  great  severity  of  both  infections  and  very 
rapid  infiltration  followed  by  extensive  suppuration 
and  destruction  of  tissue.  They  are  explained  by  the 
theory  that  a  subacute  or  latent  tuberculosis  is  stirred 
into  activity  by  the  gonococcus,  a  theory  which  is 
greatly  strengthened  by  the  recent  finding  of  tubercle 
bacilli  in  apparently  healthy  organs. 

In  the  same  way  it  may  be  said  that  the  lesions 
remaining  after  gonorrhea  are  not  likely  to  be  invaded 
by  carcinoma,  for  in  records  of  7,000  autopsies  Hasen- 
clever  found  but  forty  cases  of  vesical  carcinoma,  and 
in  the  records  of  the  Pathological  Institute  in  Munich, 
Zasnch  could  find  but  fourteen.  Carcinoma  of  the 
prostate,  too,  is  so  rare  an  affection  that  one  is  unable 
to  establish  any  relation  between  occasional  cases  and 
gonorrheal  disease. 

From  this  review  of  cases  known  to  have  the  gono- 
coccus for  their  chief  etiological  factor,  and  from  in- 
quiry into  the  various  circumstances  which  so  fre- 
quently attend  its  j)resence  it  must  be  evident  that  it 
must  be  accorded  a  position  of  great  importance  in  the 
etiology  of  disease.  And,  although  a  complete  study 
of  recent  literature  is  necessary  to  fully  appreciate 
the  number  and  variety  of  lesions  this  bacterium  may 
occasion,  the  more  novel  and  important  may  be 
summed  up  in  the  following  conclusions :  — 


IN   BOTH    SEXES.  117 

Gonorrheal  infection  may  be  one  of  the  most 
formidable  of  bacterial  invasions. 

The  virulence  of  the  gonococcus  varies  within  wide 
limits  and  reaches  its  maximum  by  prolonged  incuba- 
tion in  the  human  host. 

Nearly  all  parts  of  the  human  organism  have  been 
invaded  by  the  gonococcus. 

It  is  an  occasional  cause  of  death  by  causing  general 
peritonitis  or  general  involvement  by  distribution 
through  the  circulation. 

Its  direct  effects  are  equalled  and  perhaps  exceeded 
by  its  lesions  offering  opportunity  for  the  ingress  of 
other  bacteria. 

These  scientific  findings  are  of  great  value  to  the 
medical  profession,  the  sociologist  and  all  others  who 
seek  the  amelioration  of  social  evils. 


^: 


Fk;.   I. —  Typical  normal  glandular    unit  of    prostate  showing  the  columnar  epithelium  in  the  fibro- 
muscular  stroma.     X  6oo- 


Fk;.  2. —  Representing  section  of  prostate  in  the  first  stage  of  gonorrheal  invasion.  The  outline  of  the 
epithelium  is  lost ;  there  is  infiltration  with  small  round  cells,  which  in  places  have  replaced  the 
epithelium.     Even  the  connective  tissue  framework  is  becoming  invaded,     x  250. 


Fh;.  3. —  Showing  the  last  stages  of  gonorrheal  prostatitis  with  abscess  formation.  There  is  complete 
obliteration  of  structure,  and  there  remains  only  the  framework  to  which  pus  corpuscles  are  clinging. 
The  capsule  is  not  affected  and  has  limited  the  process.     X  90. 


Fig.  4. —  Section  of  seminal  vesicle  in  gonorrheal  inflammation.  In  the  upper  part  of  the  field  the 
epithelium  is  fairly  normal  and  shows  no  irregularities  with  this  low-  power.  Just  beneath  this  it 
will  be  seen  that  invasion  has  begun,  and  a  hand  lens  shows  the  disintegration  and  loss  of  contour. 
On  the  lower  side  of  the  lumen  a  more  advanced  stage  still  is  illustrated, —  the  structure  is  com- 
pletely obliterated  and  at  the  right  the  firm  mass  is  beginning  to  break  away.     X  40. 


Fig.  5.  —  Xormal   fold   of    mucous    membrane   of     Fallopian   tube   showing   relations  of  stroma   and 
epithelium.     X  250. 


¥iG  6. —  Section  of  Fallopian  tube  in  the  first  stage  of  gonorrheal  inflammation.  Some  of  the  folds  are 
normal  or  only  slightly  swollen,  others  show  beginning  intjltration.  In  the  lower  part  of  the  field  is 
an  examp'e  of  a  process  in  a  state  of  very  great  distension,     x  loo- 


Fig.  7. —  Showing  a  still  more  advanced  state  of  gonorrlical  infiltration.     The  folds  are  matted  together 
and  in  some  places  tl.eir  structure  is  entirely  obliterdted.     X  120. 


Fig.  8. —  Section  of  vein  in  the  substance  of  gonorrheal  Fallopian  tube.  The  picture  is  one  of  intense 
vasculitis,  the  walls  being  so  infiltrated  that  their  structure  is  obscured.  Leucocytes  are  seen  in  the 
lumen,  and  with  a  hand  lens  it  is  seen  that  the  vessel  is  in  the  act  of  distributing  septic  particles  to 
the  circulation.     X  500. 


Fig.  9. —  Section  from  frog's  stomach  into  which  i-ioo  silver  nitrate  solution  has   been  injected  and 
representing  the  normal  mucosa.     X  loo- 


Fir..  10. —  Section  of  stomach  of  frog  showing  the  result  of  injecring  i-io  silver  nitrate  solution.  At 
this  point  there  is  destruction  of  villi  and  infiltration  of  the  vestiges,  but  the  sub-mucous  tissue 
is  unaffected.     X  2so. 


F'iG.  II. —  Section  of  stomach  of  frog  which  has  been  given  1-20OC  sohition  of  corrosive  sublimate. 
The  contour  of  mucous  folds  is  obliterated  ;  there  is  desquamation  of  epithelium  and  tenacious 
mucous  has  agglutinated  the  opposite  walls.  In  other  sections  the  entire  mucous  membrane  is  in 
some  places  lacking.     X  60. 


Fig.   12. —  Same  as  Fig.  1 1,  but  stained  with  Mallory's  connective  tissue  stain   which   is  nearly  opaque 
to  chemical  rays.     X  So. 


Fig.  13. —  Section  of  tongue  of  frog  into  wliich  a  1-2000  solution  of  corrosive  sublimate  has  been 
injected.  Stained  with  JMallor>''s  connective  tissue  stain  and  showing  a  very  marked  increase  of 
that  tissue.  These  experiments  suggest  the  possibility  that  tliis  chemical  may  contribute  to  the 
etiology  of  stricture,  epididymitis  and  other  complications.     X  80. 


m^ 


